CONTINUED ON REVERSE

Transcription

1 PATIENT INFORMATION AND HEALTH HISTORY Today s Date: Patient Name: M/F Single Married Divorced Separate Widowed Date of Birth: Patient Address: Street City/State Zip Code Home Phone: Cell Phone: Work Phone: Employer: Social Security No.: Dental Insurance Carrier: Insurance No.: Hobbies (Interests): Spouse Name (If married, otherwise responsible party): Spouse Date of Birth: Spouse Employer: Spouse Work Phone: Spouse Dental Insurance Carrier: Insurance No.: Spouse Social Security No.: DENTAL HISTORY Date of last dental exam (approximate): Previous dentist s name: City: Do you have any problems in your mouth now? Yes No Do you feel nervous about having dental treatment Yes No Explain Have you ever had a bad experience in the dental office? Yes No Explain Check any of the following which you experience: Teeth sensitive to cold, heat, sweets or pressure Bad breath Bleeding gums How long: Unpleasant taste Food impaction Complications from extractions Clenching or grinding Periodontal treatment Burning of tongue Orthodontic treatment Swelling or lumps in mouth Mouth breathing Frequent blisters on lips or mouth Oral habits, i.e., fingernail biting, Pain around ear cheek biting, etc. Unusual sounds in ear while eating Check any of the following that you use: Cigarettes, pipe or cigar smoking Texture of toothbrush: Hard Soft Brushing: /day Dental Floss Inter dental stimulators Water jet device Disclosing tablets or solution Fluoride supplements CONTINUED ON REVERSE

2 PATIENT INFORMATION AND HEALTH HISTORY Present Physician: Phone Number: Are you having any health concerns at this time? Yes No Have you been a patient in the hospital during the past two years? Yes No Have you been under the care of a medical doctor during the past two years? Yes No Have you ever had any excessive bleeding requiring special treatment? Yes No Are you allergic to (i.e., itching, rash, swelling of hands, feet or eyes) or made sick by penicillin, aspirin, codeine, latex, or any drugs or medications? Yes No Explain: Have you taken any medicines or drugs during the past two years? Yes No Did you take or are you currently taking any bisphosphonates? Generic brand examples: alendronate, ibandronate, risedronate, zoledronic acid, Brand Name examples: Fosamax, Boniva, Actonel, Atelvia, Reclast Check any of the following which you have had or have at present: Heart Failure Heart Disease or Attack Angina Pectoris High Blood Pressure Heart Murmur Rheumatic Fever Congenital Heart Lesions Scarlet Fever Artificial Heart Valve Heart Pacemaker Heart Surgery Artificial Joint Arthritis Anemia Stroke Kidney Trouble Ulcers Parkinson s Disease Bruise Easy Emphysema Cough Tuberculosis (TB) Asthma Hay Fever Sinus Trouble Allergies or Hives Diabetes Thyroid Disease X-ray or Cobalt Treatment Chemotherapy (Cancer, Leukemia) Cold Sores Rheumatism Cortisone Medicine Glaucoma Pain in Jaw Joints Psychiatric Treatment Alcohol Addiction AIDS Hepatitis A (infectious) Hepatitis B (serum) Hepatitis C Liver Disease Yellow Jaundice Blood Transfusion Drug Addiction Hemophilia Venereal Disease (Syphilis, Gonorrhea) Genital Herpes Epilepsy or Seizures Fainting or Dizzy Spells Nervousness Sickle Cell Disease Other please list: Do you need to take pre-medication for dental work due to having artificial joint or heart valve? Yes No If Yes, please state reasoning for pre-med: WOMEN: Are you pregnant now? Yes No If yes, how far along? Are you presently taking oral contraceptives? Yes No Do you anticipate becoming pregnant? Yes No The information on this page is correct to the best of my knowledge. I hereby authorize the dental office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. I also understand the use of anesthetic agents embodies a certain risk. The risks include, but are not limited to pain, swelling, bruising and permanent anesthesia. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail. IN-OFFICE USE ONLY Date: Signature: / Patient or Responsible Party BP P Reviewed by Date The parties agree that this document may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. The undersigned patient further consents to the employee of Szmanda Dental Center, SC entering my electronic signature on my Patient Health History form in connection with a review(s) conducted at my scheduled appointment(s) You may withdraw your consent to the use of electronic signatures at any time. In order to withdraw consent you must notify Szmanda Dental Center, SC in writing that you wish to withdraw consent and request that your future documents be provided in paper format.

3 FINANCIAL POLICY Thank you for choosing us as your dental care provider. We are committed to maintaining high standards of comprehensive dental care. Financial considerations should not be an obstacle to obtaining care. Being sensitive to the fact that people have different needs in fulfilling their financial obligations, we provide the following payment options. FOR PATIENTS WITHOUT INSURANCE We ask that you PAY IN FULL the day of service. We accept CASH, CHECK, or CREDIT CARD MasterCard, Visa, Discover, American Express, and Care Credit. To demonstrate our appreciation we will extend a five percent (5%) reduction of your total fee. FOR PATIENTS WITH INSURANCE We are happy to assist you in filing the necessary forms. The insurance relationship constitutes an agreement between the carrier and the patient. We can make no guarantee of estimated coverage for payment. However, be assured we will do everything possible to help you receive the full benefits of your policy. We ask that YOUR CO-PAY BE PAID AT THE TIME OF SERVICE. MONTHLY PAYMENT PLAN For balances OVER $ Pay one half on the day procedure is started and the balance upon completion. 2. To qualified applicants, an Interest Free Plan may be offered by CareCredit. No interest charges are assessed if paid within the specified interest free periods of six(6) or twelve(12) months with no prepayment penalties. Get pre approved at CareCredit.com I understand that I am ultimately responsible for all charges incurred for dentistry performed upon myself or my dependants in this dental office. Any Insurance Claim not paid in full after 60 days will become my responsibility to pay at that time. Thank you for trusting us with your dental care and for understanding our Financial Policy. Please feel free to contact our staff if you have any questions regarding the payment options described above. I have read and agree to this financial policy. DATE: SIGNED: PATIENT OR RESPONSIBLE PARTY

4 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS National TO Alternative THIS Security: INFORMATION.PLEASE Communication: We may disclose REVIEW You to have military IT CAREFULLY. the authorities right to THE request PRIVACY the health that OF information we YOUR communicate HEALTH of Armed INFORMATION with Forces you about IS personnel IMPORTANT your health under TO US. certain information circumstances. by alternative We may means disclose or to to alternative authorized locations. federal officials (You health must make information your required request for in writing.) lawful intelligence, counterintelligence, Your request must and specify other national alternative security means activities. or location, We and may provide disclose satisfactory to correctional explanation institution of or how law enforcement official OUR payments LEGAL having DUTY lawful will be custody handled of under protected the alternative health information means or of location inmate or you patient request. under certain circumstances. We are required by applicable federal and state law to maintain the privacy of your health information. We are also Appointment required Amendment: to give Reminders: you You this have Notice We the about may right use our to request or privacy disclose that practices, your we amend health our legal information your duties, health to and information. provide you rights you (Your with concerning appointment request your must health reminders be (such information. as writing, voice We and mail must it messages, must follow explain the , privacy why text the practices messages, information that postcards, are should described or amended.) letters) in this Notice We may while deny it is in your effect. request This under Notice takes effect certain (03/05/15), circumstances. and will remain in effect until we replace it. We reserve the right to change our privacy practices and the PATIENT terms of this RIGHTS Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the Access: changes Electronic in You our have privacy the Notice: practices right to look If you receive and at the or get this new copies Notice terms of on of your our Web Notice health site effective information, or by electronic all with health limited exceptions. You may request that we provide copies a format other than photocopies. We will use the format you mail information request ( ), unless you that we are we cannot entitled maintain, including health information we created or received before we made the changes. Before we make a significant change practicably do to receive so. (You this must Notice make in a written request form. in our privacy practices, we will change this in writing Notice to and obtain make access the new to your Notice health available information. upon request. You may obtain a form to request access by using the contact information listed at the time. You may also request access by sending us a letter to the USES address AND DISCLOSURES at the end of this OF Notice. HEALTH If you INFORMATION request copies, we will charge you $1.00 for each page, for staff time to locate and We use copy and your disclose health health information, information and postage about you if you for want treatment, the copies payment, mailed and to healthcare you. If you operations. request an alternative For example: format, we will QUESTIONS charge a cost-based AND COMPLAINTS fee for providing your health information in that format. If you prefer, we will prepare a summary Treatment: or an We explanation may use or of disclose your health your information health information a fee. to a Contact physician us or using other the healthcare information provider listed at providing the end of this Notice treatment If you for want to a full you. more explanation information of our about fee structure.) our privacy practices or have questions or concerns, please contact us. Disclosure Payment: If you are We Accounting: concerned may use and You that disclose have the we may your right have health to receive violated information a list of your privacy to instances obtain rights, payment in which or you disagree for we services or our with we business a provide associates decision to we you. made disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other about access to your health information or in response to a request you made to amend or restrict the use or activities, Healthcare for disclosure Operations: the last 6 years, of your health We but information may not use before and or disclose April 14, to have us your communicate health If you information request this with you in connection accounting by alternative with more means our than healthcare once in a or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also operations. 12-month period, Healthcare we may operations charge include you a reasonable, quality assessment cost-based and fee improvement for responding activities, to these reviewing additional the requests competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, Restriction: may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you certification, licensing You have or the credentialing right to request activities. that we place additional restrictions on our use or disclosure of your health information. with the address We are not to file required your complain to agree with to these U.S. additional Department restrictions, of Health but if and we do, Human we will Services abide by upon our request. agreement (except Your Authorization: in an emergency). In addition to our use of your health information for treatment, payment or healthcare operations, you We may support give us your written right authorization to the privacy to use of your your health information. or We to will disclose not retaliate it to anyone in any for way any if purpose. you choose If you Alternative give to us file an a authorization, complaint Communication: with you us may or You with revoke have the the U.S. it in right writing Department to request at any of time. that Health we Your communicate and revocation Human Services. will with not you affect about any your use health or disclosures information by permitted alternative by your means authorization to alternative while it locations. was in effect. (You Unless must make you give your us request a written in authorization, writing.) Your we request cannot must use or specify alternative disclose your means health or information location, and for provide any reason satisfactory except explanation those described of how in this payments Notice. will be handled under the alternative means or location you request. Contact Officer: Kerry Shelly Kristi Penny Patti To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights Amendment: section You have the right to request that we amend your health information. (Your request must be in writing, and it must Telephone: of this Notice. explain why (715) We the may disclose your information should Fax: health be amended.) (715) Fax: information (715) We to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your may healthcare, deny your but request only if under you agree certain that circumstances. we may do so. Electronic Notice: wausau@szmandadental.com marathon@szmandadental.com wittenberg@szmandadental.com edgar@szmandadental.com info@szmandadental.com Persons Involved in If Care: you receive We may this use Notice or disclose our Website health information by electronic to notify, mail or ( ), assist in you the are notification entitled to of receive (including this Notice identifying in written or locating) form upon a family request. member, your personal representative or another person responsible for your care, of your location, Address: your general Main E. S. Hummingbird condition, Grand 3rd Street, Avenue, or PO death. Edgar, Road, Box Wausau, Wittenberg, 488, If Wausau, WI you WI Marathon, are present, WI WI then prior to use or disclosure of your health information, we Failed will provide Appointment: you with an If opportunity you repeatedly to object miss to your such scheduled uses or disclosures. appointment(s), In the we event reserve of your the right incapacity to charge or emergency you a cancellation circumstances, fee we as will it is disclose at the expense health information of our staff s based time and on a wages, determination and an inconvenience using our professional to our other judgement potential disclosing patients. only health information that is directly relevant to the person s involvement in your healthcare. We will also use our QUESTIONS professional judgment AND COMPLAINTS and our experience with common practice to make reasonable inferences of your best interest in If allowing you want a person more information to pick up filled about prescriptions, our privacy practices medical supplies, or have questions x-rays, or or other concerns, similar please forms of contact health us. information. If Marketing you are concerned Health-Related that we Services: may have We violated will not your use privacy your health rights, information you disagree for marketing with a decision communications we made about without your access written authorization. to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may contact us Required at one of by the Law: locations We may listed use below. or disclose You also your may health submit information a written when complaint we are to required the U.S. to Department do so by law. of Health and Human Services. We will provide you with the address to file your complain with the U.S. Department of Health and Human Abuse or Services Neglect: upon We request.we may disclose support your your health right information to the privacy to appropriate of your health authorities information. if we reasonably We will not believe retaliate that in you any are a way possible if you victim choose of to abuse, file a complaint neglect, or with domestic us or with violence the U.S. or the Department possible victim of Health of other and crimes. Human Services. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

5 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS National TO Alternative THIS Security: INFORMATION.PLEASE Communication: We may disclose REVIEW You to have military IT CAREFULLY. the authorities right to THE request PRIVACY the health that OF information we YOUR communicate HEALTH of Armed INFORMATION with Forces you about IS personnel IMPORTANT your health under TO US. certain information circumstances. by alternative We may means disclose or to to alternative authorized locations. federal officials (You health must make information your required request for in writing.) lawful intelligence, counterintelligence, Your request must and specify other national alternative security means activities. or location, We and may provide disclose satisfactory to correctional explanation institution of or how law enforcement official OUR payments LEGAL having DUTY lawful will be custody handled of under protected the alternative health information means or of location inmate or you patient request. under certain circumstances. We are required by applicable federal and state law to maintain the privacy of your health information. We are also Appointment required Amendment: to give Reminders: you You this have Notice We the about may right use our to request or privacy disclose that practices, your we amend health our legal information your duties, health to and information. provide you rights you (Your with concerning appointment request your must health reminders be (such information. as writing, voice We and mail must it messages, must follow explain the , privacy why text the practices messages, information that postcards, are should described or amended.) letters) in this Notice We may while deny it is in your effect. request This under Notice takes effect certain (03/05/15), circumstances. and will remain in effect until we replace it. We reserve the right to change our privacy practices and the PATIENT terms of this RIGHTS Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the Access: changes Electronic in You our have privacy the Notice: practices right to look If you receive and at the or get this new copies Notice terms of on of your our Web Notice health site effective information, or by electronic all with health limited exceptions. You may request that we provide copies a format other than photocopies. We will use the format you mail information request ( ), unless you that we are we cannot entitled maintain, including health information we created or received before we made the changes. Before we make a significant change practicably do to receive so. (You this must Notice make in a written request form. in our privacy practices, we will change this in writing Notice to and obtain make access the new to your Notice health available information. upon request. You may obtain a form to request access by using the contact information listed at the time. You may also request access by sending us a letter to the USES address AND DISCLOSURES at the end of this OF Notice. HEALTH If you INFORMATION request copies, we will charge you $1.00 for each page, for staff time to locate and We use copy and your disclose health health information, information and postage about you if you for want treatment, the copies payment, mailed and to healthcare you. If you operations. request an alternative For example: format, we will QUESTIONS charge a cost-based AND COMPLAINTS fee for providing your health information in that format. If you prefer, we will prepare a summary Treatment: or an We explanation may use or of disclose your health your information health information a fee. to a Contact physician us or using other the healthcare information provider listed at providing the end of this Notice treatment If you for want to a full you. more explanation information of our about fee structure.) our privacy practices or have questions or concerns, please contact us. Disclosure Payment: If you are We Accounting: concerned may use and You that disclose have the we may your right have health to receive violated information a list of your privacy to instances obtain rights, payment in which or you disagree for we services or our with we business a provide associates decision to we you. made disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other about access to your health information or in response to a request you made to amend or restrict the use or activities, Healthcare for disclosure Operations: the last 6 years, of your health We but information may not use before and or disclose April 14, to have us your communicate health If you information request this with you in connection accounting by alternative with more means our than healthcare once in a or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also operations. 12-month period, Healthcare we may operations charge include you a reasonable, quality assessment cost-based and fee improvement for responding activities, to these reviewing additional the requests competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, Restriction: may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you certification, licensing You have or the credentialing right to request activities. that we place additional restrictions on our use or disclosure of your health information. with the address We are not to file required your complain to agree with to these U.S. additional Department restrictions, of Health but if and we do, Human we will Services abide by upon our request. agreement (except Your Authorization: in an emergency). In addition to our use of your health information for treatment, payment or healthcare operations, you We may support give us your written right authorization to the privacy to use of your your health information. or We to will disclose not retaliate it to anyone in any for way any if purpose. you choose If you Alternative give to us file an a authorization, complaint Communication: with you us may or You with revoke have the the U.S. it in right writing Department to request at any of time. that Health we Your communicate and revocation Human Services. will with not you affect about any your use health or disclosures information by permitted alternative by your means authorization to alternative while it locations. was in effect. (You Unless must make you give your us request a written in authorization, writing.) Your we request cannot must use or specify alternative disclose your means health or information location, and for provide any reason satisfactory except explanation those described of how in this payments Notice. will be handled under the alternative means or location you request. Contact Officer: Kerry Shelly Kristi Penny Patti To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights Amendment: section You have the right to request that we amend your health information. (Your request must be in writing, and it must Telephone: of this Notice. explain why (715) We the may disclose your information should Fax: health be amended.) (715) Fax: information (715) We to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your may healthcare, deny your but request only if under you agree certain that circumstances. we may do so. Electronic Notice: wausau@szmandadental.com marathon@szmandadental.com wittenberg@szmandadental.com edgar@szmandadental.com info@szmandadental.com Persons Involved in If Care: you receive We may this use Notice or disclose our Website health information by electronic to notify, mail or ( ), assist in you the are notification entitled to of receive (including this Notice identifying in written or locating) form upon a family request. member, your personal representative or another person responsible for your care, of your location, Address: your general Main E. S. Hummingbird condition, Grand 3rd Street, Avenue, or PO death. Edgar, Road, Box Wausau, Wittenberg, 488, If Wausau, WI you WI Marathon, are present, WI WI then prior to use or disclosure of your health information, we Failed will provide Appointment: you with an If opportunity you repeatedly to object miss to your such scheduled uses or disclosures. appointment(s), In the we event reserve of your the right incapacity to charge or emergency you a cancellation circumstances, fee we as will it is disclose at the expense health information of our staff s based time and on a wages, determination and an inconvenience using our professional to our other judgement potential disclosing patients. only health information that is directly relevant to the person s involvement in your healthcare. We will also use our QUESTIONS professional judgment AND COMPLAINTS and our experience with common practice to make reasonable inferences of your best interest in If allowing you want a person more information to pick up filled about prescriptions, our privacy practices medical supplies, or have questions x-rays, or or other concerns, similar please forms of contact health us. information. If Marketing you are concerned Health-Related that we Services: may have We violated will not your use privacy your health rights, information you disagree for marketing with a decision communications we made about without your access written authorization. to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may contact us Required at one of by the Law: locations We may listed use below. or disclose You also your may health submit information a written when complaint we are to required the U.S. to Department do so by law. of Health and Human Services. We will provide you with the address to file your complain with the U.S. Department of Health and Human Abuse or Services Neglect: upon We request.we may disclose support your your health right information to the privacy to appropriate of your health authorities information. if we reasonably We will not believe retaliate that in you any are a way possible if you victim choose of to abuse, file a complaint neglect, or with domestic us or with violence the U.S. or the Department possible victim of Health of other and crimes. Human Services. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

6 WISCONSIN CONSENT Purpose: This form is to obtain an individual s written permission under Wisconsin Law for (A) our use of the individual s dental care records to carry out treatment, payment activities, and health care operations, and (B) our disclosure of the individual s dental care records to carry out treatment, payment activities, and health care operations. SECTION A: Individual giving consent Name: Patient Name: (If different than above) Address: Telephone: TO THE INDIVIDUAL: Please read the following and complete the information requested Effect of Declining Consent: This consent is a condition of your treatment by us. If you decide not to sign this consent, we may decline to treat you. Privacy Practices Notice: You have the right to read our Privacy Practices Notice before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and health care operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our dental office s Notice of Privacy Practices accompanies this consent. We encourage you to read it carefully and completely before signing this consent. SECTION B: The uses and disclosures being authorized Our Use of Dental Health Information: By signing this form, you will consent to our use of your dental care records, to carry out treatment, payment activities, and health care operations as set forth in our Privacy Practices Notice. Persons Involved in Care: By signing this form, you will consent to our use of your dental care records to the following person, including those involved in your care or payment for that care. Please list the person(s) you would like involved in your care or payment for that care. We may use professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person acting on your behalf to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of protected health information. Our Disclosure of Medical Information: By signing this form, you will consent to our disclosure of your dental care records to carry out treatment, payment activities, and health care operations as set forth in our Privacy Practices Notice, and to our disclosure of your dental care records for disaster relief purposes as permitted by law. SECTION C: Revocation Right to Revoke: This consent is effective until revoked by you. You may revoke this consent at any time by giving written notice of revocation to the Contact Office checked below. Revocation of this consent will not affect any action we took in reliance on this authorization before we received your written notice of revocation. We may decline to treat you or to continue treating you if you revoke this consent. continued on next page

7 WISCONSIN CONSENT INDIVIDUAL S SIGNATURE I,, have had full opportunity to read and consider the contents of this consent. I understand that, by signing this for, I am confirming my written permission for the disclosure of my protected health information, as described in this form. Signature: Date: If this consent is signed by a personal representative/parent on behalf of the individual, complete the following: Personal Representative s/parent Name: Relationship to Individual: ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I have received a copy of this office s Notice of Privacy Practices. Please Print Name: Signature: Date: FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify)

8 CHILD PATIENT HEALTH HEALTH INFORMATION HISTORY HISTORY PATIENT INFORMATION DENTAL AND HEALTH HISTORY HISTORY FORM AND HEALTH HISTORY Patient s Name Nickname Date of Birth Version June 16, 2015 LAST FIRST INITIAL Today s Date: Present Physician: Phone Today s Number: Date: Patient Parent s/guardian s Name: Name Relationship Single to Married Patient Divorced School Separate Child Attends Widowed Are Date: you having Signature: any health concerns at this time? Yes / No Date Patient of Birth: Name: Single Married Divorced Separate Widowed Address Patient or Responsible Party BP P Reviewed by Date Patient MEDICAL Have Date Please of you Address: Print UPDATES PO Birth: OR been MAILING Name: a patient ADDRESS in the hospital during CITY the past two years? STATE Yes No ZIP CODE I have read my MEDICAL Street HISTORY and confirm that it adequately City/State states past and present conditions. Zip Code Home Patient Phone Phone: Address: Sex M F DATE Address: EXCEPTIONS Cell Phone: PATIENT S SIGNATURE Work Phone: BP REVIEWED BY Have you HOME been under Street the care of a medical doctor WORKduring City/State the past two years? Yes No Zip Code Employer: Social Security No.: / Home Phone Parent s/guardians Phone: Number: Employer Cell Phone: Dental Insurance Work Carrier Phone: Insurance No. Dental Insurance Carrier: Insurance No.: / Employer: Have you ever had any excessive bleeding requiring Social Security special No.: treatment? Yes No Spouse Have you Name (the parent/guardian) or the (If married, otherwise responsible party): patient had any of the following diseases Spouse or problems?... / Date of Birth: Yes No Spouse Dental 1. Active Tuberculosis Insurance 2. Persistent cough greater Employer: Carrier: than a three-week duration 3. Cough that Spouse Insurance Work Phone: No.: / produces blood? If you answer Date: Are you allergic yes to any of the three items above, to (i.e., itching, rash, swelling of hands, please stop and return this form to feet or eyes) or made sick by / the receptionist. penicillin, aspirin, codeine, Spouse Hobbies Dental (Interests): Insurance Carrier: Insurance No.: latex, Has the child or any had any history of, or conditions related drugs or medications? Yes to, any of the following: No Explain: / Spouse Anemia Social Name Security (If married, Cancer otherwise No.: responsible party): Epilepsy HIV +/AIDS Have you Spouse been Mononucleosis Date a patient of Birth: in the hospital Thyroiduring the Have Arthritis you taken any medicines Cerebral Palsy or drugs Fainting during the past two Immunizations years? Yes Mumps No Tobacco/Drug Use past year? Yes No Explain: Spouse Asthma Chicken Pox Growth Problems Kidney Pregnancy (teens) Tuberculosis Are How Employer: Spouse Work Phone: Bladder you did allergic you hear to (i.e., about Chronic itching, us Sinusitis rash, or what swelling made Hearing of hands, you feet choose or eyes) Szmanda Latex Allergy or made sick Dental by penicillin, Center? Rheumatic Fever Venereal Disease aspirin, codeine, latex, or any drugs Spouse please Did Bleeding you check or medications? Dental take disorders all Insurance are that you apply Diabetes currently Yes Carrier: taking Heart No any bisphosphonates? Liver Explain: Insurance Generic brand Seizures No.: examples: alendronate, Other Bones/Joins Ear Aches Hepatitis Measles Sickle Cell ibandronate, risedronate, zoledronic acid, Brand Name examples: Fosamax, Boniva, Actonel, Atelvia, Reclast Have Spouse Social you Social taken any Security medicines No.: or drugs during the past two years? Yes No Explain: Check Name any of Media Child s of the Physician following which you have had or have at present: Phone If yes, which CHECK platform(s): ANY OF THE FOLLOWING WHICH YOU HAVE HAD OR HAVE AT PRESENT: Is Heart this your Failure childs first trip to the Stroke dentist? Y N If no, X-ray please or Cobalt list previous Treatment dental office Yellow Jaundice Newspaper Heart Heart Disease Failure Ad or Attack Kidney Anemia Trouble DENTAL HISTORY Chemotherapy Thyroid Disease (Cancer, Leukemia) Blood Hepatitis Transfusion C Angina Heart Pectoris Disease or Attack Ulcers Stroke Approximate Cold Sores X-ray date or Cobalt of last Treatment visit Drug Liver Addiction Disease High Blood If yes, Angina Pressure which newspaper(s): Pectoris Parkinson s Kidney Disease Trouble Rheumatism Chemotherapy Hemophilia Yellow Jaundice Heart High Murmur Blood Pressure Bruise Ulcers Easy Cortisone (Cancer, Medicine Leukemia) Blood Venereal Transfusion Disease (Syphilis, Gonorrhea) Date 1. Is Phonebook the Rheumatic of child last taking dental Ad exam (approximate): Heart Fever any prescription and/or Murmur Emphysema over the counter medications Parkinson s Disease Glaucoma or vitamin supplements at this time?... Cold Sores Drug Genital Addiction Herpes 1. Y N if yes, Previous Congenital please Rheumatic dentist s If yes, Heart list: which Fever Lesions name: phonebook: Cough Bruise Easy Pain in Rheumatism Jaw Joints City: Hemophilia Epilepsy or Seizures 2. Is the Scarlet child Congenital Fever allergic to Heart any medications, Lesions Tuberculosis i.e. penicillin, Emphysema (TB) antibiotics, or other Psychiatric drugs? Cortisone If Treatment yes, Medicine please explain: Venereal Fainting or Disease Dizzy Spells 2. Y N (Syphilis, Gonorrhea) Do 3. Is Internet you the Artificial child have Scarlet allergic Heart Search any Fever Valve to problems anything else, in such Asthma your as Cough certain mouth foods? now? If yes, please Yes Alcohol explain: Glaucoma Addiction No Genital Nervousness Herpes 3. Y N 4. How Heart would Artificial Pacemaker If you yes, describe Heart which Valve the search child s eating Hay engine: Fever habits? Tuberculosis (TB) AIDS Pain in Jaw Joints Epilepsy Sickle Cell or Disease Seizures Do 5. Has you Heart the feel child Heart Surgery nervous ever Pacemaker had a about serious illness? having Sinus If yes, Asthma Trouble dental when: treatment Hepatitis Yes Please Psychiatric A (infectious) describe: No Treatment Explain Fainting Other please or Dizzy list: Spells 5. Y N Heart Surgery Hay Fever Alcohol Addiction Nervousness Have 6. Has Word Artificial you the child of Joint Mouth ever ever had been We a hospitalized? would Allergies bad experience... love to or know Hives who to thank! Hepatitis B (serum) in the dental office? Yes No Explain 6. Y N 7. Does Arthritis the Artificial child have Joint a history of any other Diabetes illnesses? Sinus Trouble If yes, please list: Hepatitis AIDS C Sickle Cell Disease 7. Y N Check 8. Has Anemia the any child Arthritis Thyroid of the following which you Allergies Disease experience: or Hives Liver Disease Referral ever received Name: a general anesthetic?... Hepatitis Referral A (infectious) Contact: Other please list: 8. Y N 9. Does the child have any inherited problems? Diabetes... Hepatitis B (serum) 9. Y N 10. Do Does Direct you the need child Mail have to Piece take any speech pre-medication difficulties? for dental work due to having artificial joint or heart valve? Y N 11. Do Has you need to take pre-medication for dental work due to having artificial joint or heart valve? Yes the child Teeth ever No had sensitive If a Yes, blood transfusion? please to cold, state heat, sweets reasoning or pressure for pre-med: Bad breath Y N 12. Is the Yes child If physically, yes, Bleeding No was If mentally, Yes, it because gums please or How emotionally state of the long: reasoning impaired? incentive? for pre-med: yes no Y N Unpleasant taste 13. WOMEN: Does Local the Event/Donation child Are experience Food you impaction pregnant excessive now? bleeding when Yes cut? Y N No If yes, how far along? Complications from extractions 14. WOMEN: Is the child Are you presently Are currently Clenching you being taking pregnant treated or oral grinding now? for any illnesses? If yes, do you recall contraceptives? what Yes Y N event/donation: No Yes If yes, No how Do far you along? anticipate 15. Is this the child s first visit to a dentist? If not the first visit, what was the date of the last dentist Periodontal visit? becoming Date: treatment 15. pregnant? Yes No Y N 16. Are you presently Burning taking of tongue oral contraceptives? Yes No Do you anticipate Orthodontic becoming treatment pregnant? Yes No The Has information Other: child on had this any page problem is correct with dental to the treatment best of my in knowledge. the past? Y N I hereby authorize the dental office to administer such medications and 17. The information Swelling on this page or is lumps correct in to the mouth best of my knowledge. I hereby authorize the Mouth dental office breathing perform Has the such child diagnostic, ever had photographic dental radiographs and therapeutic (x-rays) exposed? procedures as may be necessary for proper dental to care. administer I also such understand medications the use and Y N of 18. perform anesthetic Has the such agents child diagnostic, Frequent ever embodies suffered photographic blisters a any certain injuries on risk. and lips to therapeutic The or risks mouth, include, procedures head or but teeth? are as not may limited be necessary to pain, swelling, for Oral proper habits, bruising dental i.e., and care. permanent fingernail also understand anesthesia. biting, the use If I have Y of N 19. anesthetic agents embodies certain risk. The risks include, but are not limited to pain, swelling, bruising and permanent anesthesia. If have any Has changes the child in my Pain had health any around problems status ear or with if my the medicines eruption or change, shedding I shall of teeth? inform the dentist and staff cheek at the biting, next appointment etc. without fail. Y N 20. Has the child Unusual had any orthodontic sounds treatment? in ear while eating Y N 21. What type of water does your child drink? IN-OFFICE USE ONLY IN-OFFICE USE ONLY 22. Does the Check child take any fluoride of the supplements? following that you use: Y N 23. Date: Is fluoride toothpaste Cigarettes, Signature: used? pipe or cigar smoking / Inter dental stimulators Y N 24. How many times are the child s teeth brushed Texture of toothbrush: Patient Patient per Hard or or day? Responsible Responsible Soft Party Party When are the teeth BP BP brushed? 24. Water jet P device Reviewed Reviewed by by Date Date Y N 25. Does the child suck his/her thumb, fingers or pacifier? Y N 26. At what age did Brushing: the child stop /day bottle feeding? Age Breast feeding? Age Disclosing tablets or solution 27. Dental Floss Fluoride supplements MEDICAL MEDICAL Does the child UPDATES UPDATES participate I in have have active read read recreational my my MEDICAL MEDICAL activities HISTORY HISTORY and and confirm confirm that that it it adequately adequately states states past past and and present present conditions. conditions. Y N NOTE: DATE DATE Both doctor EXCEPTIONS EXCEPTIONS and patient are encouraged to discuss any PATIENT S PATIENT S and all relevant SIGNATURE SIGNATURE patient health issues prior BP BP to treatment. REVIEWED REVIEWED BY BY I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold CONTINUED ON REVERSE my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions / / that I may have made in the completion of this form. Parent s/guardian s Signature / / Date: Main St. PO / / Box Grand Ave. For Office Use Only Wausau, - Dentist WI Comments: / / Medical Alert Premedication Allergies Anesthesia Reviewed by: Date: