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Health History Form

Happy Tooth Happy Patient. Happy Dentist. Today's Date:

Email:

Name:

( ) Home Phone

Mi.

First

( ) Cell Phone

Address: Mailing Address

M Date o f Birth married

widowed

.State

City

F

Sex

Age single divorced

partnered

Height

Weight

SS#

minor Occupation

Marital Status (circle) Emergency Contact

Zip

( • ) Home Phone

Relationship

( ) Cell Phone

If you are completing this form for another person, what is your relationship to that person? Name:

Dental Information

Relationsip: Please mark (X) in response to the following questions. Yes No DK

Yes No DK

• • • • •

Do your gums bleed when you brush or floss? Are your teeth sensitive to cold, hot, sweets, or pressure? Is your mouth dry? Have \ o u had any periodontal (gum) treatments? Have you had any orthodontic (braces) treatments?

• • • • •

• • • • •

Do you have earaches or neck pains? Do you have any clicking or discomfort in the jaw? Do you brux or grind your teeth? Do .you have sores or ulcers in your mouth'' Do you wear dentures or partials? Do you participate in active recreational activities?

Have you had any problems associated with previous dental treatment''

• • • •

Is your home water supply fluoridated? Do you drink bottled or filtered water? Are \ou currently experiencing dental pain or discomfort?

• • • •

• • • •

Have you ever had a serious injury to your head?

• • • • • • •

• • • • • • •

• • • • • • •

Date of your last dental exam: what was done at that time?

What is the reason for today's visit? How do you feel about your smile?

Medical Information

Please mark (X) in response to indicate if you ha\ or have had any of the following Yes No DK

Yes No DK

• • •

Are \ou now under the care of a physician? Pysician's name;

Have you had a serious illness, operation or been

Phone:

hospitalized in the past five years?

(

If yes, what was the illness or problem?

)

• • •

Address. City, State, Zip: Are you taking or have you recently taken any prescription Are \ou in good health? Any health changes within the past year? If yes, what condition is being treated?

Date of last physical exam:

• • • • • •

or over the counter medicine(s)? If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements:

• • •

Medical Information

Please mark (X) in response to indicate ifyou have or have had any of the following Yes No DK

• • •

Do \ou wear contact lenses''

Joint Replacement.

Have you had an orthopedic joint

• • • • • •

Do you use tobacco

• • • • • •

(hip. knee, elbow, finger) replacement? Date:

Yc^ N o D K Do you use controlled substances (drugs)?

I f yes, any complications?

If so are you interested in stopping? (circle one) . verj'

somewhat

not interested

• • •

Are >ou taking or scheduled to begin taking an antiresorptive agent

Do you drink alcoholic beverages?

(like Fosamax. Actonel, Atelvia, Boniva, Reclast, Prolia) for

If so, how much did you drink in the past 24hrs?

• • •

osteoporosis or Paget's disease?

If so, how much do you typicall\k in a week''

Since 2001, were you treated or are \ou presently scheduled to begin

WOMEN ONLY:

treatment with an antiresorptive agent for bone pain, hypercalcemia

Are you Pregnant?

or skeletal complications resulting from Paget's disease, mutiple myeloma or matestatic cancer?

• • • • • • • • •

Asprin? Penecillin or other antibiotics? Barbiturates, sedatives, or sleeping pills? Sulfa drugs? Codeine or other narcodics?

Nursing?

• • • • • •

• • • • • •

Latex (rubber)? Iodine? Hay Fever/sesonal? Animals? Food? Other''

Yes No DK

• • • • • • • • •

Artificial (prosthetic) heart valve Previous infective endocarditis Damaged valves in transplanted heart

Unrepaired, cyanotic C H D Repaired (completely) in last 6 months Repaired CHD with residual defects

Arteriosclerosis

•

• •

•

Mitral • valve prolapse Pacemaker

•

•

• Rheumatic fever

Congestive heart failure

D

D

DRheumatic heart disease

Damaged heart valves

•

•

•Abnormal bleeding

Heart attack

•

•

• Anemia

O D D Blood transfusion

Heart murmur •

•

•

High blood pressure

•

•

• Hemophilia

•

•

• Arthritis

• • • • • • • • • •

• • • • • • • • • •

• • • • • • • • •

Glaucoma

Rheumatoid arthritis

•

Hepatitis, jaundice

• • •

antibiotics prior to your dental treatment? Name of physician or dentist making recommendation:

Name

•

• • D • •• D• •• •

Bronchitis Emphysema Sinus trouble Tuberculosis

• • • • • •

Radiation treatment Chest pain upon exertion Chronic pain Diabetes Type 1 or 11

Malnutrition Gastrointestinal disease

•

• D• D• •• •• D • ••

• • • • • • •

•

• • • •• • •

• • • •

Sexually transmitted disease

Do you have any disease, condition, or problem not listed

Fainting spells Seizures

• • • • • • • • •

• • • • • • •

• • • •

• • • •

• • •

if yes, specify:

Do you snore?

• • • • • •

Mental health disorders

• • •

i f yes, specify: Recurrent infection Kidney problems Night sweats

• • • •

• • • •

• • • •

Persistant swollen glands in neck , Severe headaches

• • • • • •

Severe weightloss Excessive urination

•

• • • • • • • • •

Neurological disorders

Osteoporosis

G.E. Reflux/ persistant

Ulcers

Epilepsy

Sleep disorder

Cancer/Chemotherapy/

Stroke

)

phone

above that \ou think 1 should know about''

Asthma

Thyroid problems

(

or liver disease

Systemic lupus

heartburn

1 las a ph\sician or previous dentist recommended that you take

• • • •

• • • • • • • • •

Yes No DK

D

Eating disorder

AIDs or HIV infection

Other congenital

• • • • • • • • • •

if yes, date:

Low blood pressure

heart defects

YesNoDK Autoimmune disea.se

erythematosus

Congenital heart disease (CHD)

•

DK

Metals?

Local anesthtic?

Angina

Yes No

Taking birth control pills or hormonal replacement?

•Vilergies. Are you allergic to or have you had a reaction to:

Cardiovascular desease

due date

• • •

• •

• • •

N O T E : Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

1 certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a tru health history and that my dentist and his/her staff will rely on this information for treating me. 1 acknowledge that my questions, if any. about i set forth above have been answered to my satisfatction. I will not hold my dentist or any other member of his/her statT. responsible for any act take or do not take because of errors or omissions that I may have made in the completion of this form. Signature of Patient/Legal Guardian:

Date:

HAPPY TOOTH HAPPY PATIENT. HAPPY DENTIST.

PATIENT NAME:

.

DATE:

/

/

Primary Dental Insurance Dental Insurance Company^

:

Name of Insured/Policy holder Member ID/SSN Employee Date of Birth

/

. Group Number /

Employer

\

Secondary/Additional Dental Insurance

•

Dental Insurance Company

^

Name of Insured/Policy holder

:

Member ID/SSN Employee Date of Birth

.

Group Number /

/

Employer

,

^

Please check one of the statements below: • I have no other insurance policy other than with

Dental Insurance.

• I have dual insurance policies and have given all policy information to Happy Tooth.

I hereby swear or affirm, under oath and penalty of perjury, that the contents of this document are true and co

Signature: Printed Name/Guardian:

Date:

/

/

Dental insurance benefits are designed to share the cost of your dental care. Your plan

nnay not cover the total cost of treatment, leaving a copayment. Our staff will try to give you the best estimate treatment costs, but cannot always predict the exact level of coverage for a particular procedure.

It is

responsibility, as the insured patient, to be aware of the benefits provided by your insurance, includin limitations and exclusions.

If you have any questions regarding your co-pay or coverage, please ask

treatment is initiated. We will gladly answer any questions or direct you to a source that might be helpful.

All co-payments are due at the time of service.

Any balance not paid by insurance will be assigned to the patient (or responsible party) and will become the responsib patient (or responsible party) to be handled by the next statement cycle. Any overdue balance at 30 days will be subject to of $25 per monthly statement cycle. Patients with an outstanding balance of 90 days will be referred to the Credit Bur Collections Service, unless another written agreement has been made with the dentist or office manager.

Appointments are expected to be kept. As a courtesy, the office staff will call ahead to confirm the appointment time and there is no communication with clinic staff, the patient is still responsible for attendance. Cancellations can be done b before the appointment. Any cancellations after this time will be considered a failed appointment. Patients with appointments will be charged a $10 fee per 15 minutes scheduled (Ihr = $40). These fees will not be waived.

Patient records and radiographs are the property of the clinic. Any hard copy record of treatment done at Happy Tooth mu inside the clinic. Duplication of records and radiographs can be done for a $30 fee. Patient records (including x-rays) released unless there is a $0 balance on patient account.

Payment plans are not offered through Happy Tooth. The only form of payment plan offered to a patient is thru CareCredi plans vary from 6 to 48 months, with interest rates as low as 0%. Our office accepts prepayments for treatment planne dentist. A 5% discount will be given when full payment is received prior to treatment. This does not apply to payme CareCredit.

Patients will be given a treatment plan, with fees and co-pays, to be signed prior to initial treatment. You will not be all make an appointment without a signed treatment plan. Any appointment demanding two hours or more will require nonrefundable down payment to hold your appointment.

All patients using insurance benefits must present both insurance card and an identification card (driver's license state you were not given an insurance card and we cannot verify your information, the services will be charged to the responsib the time of delivery. We may ask to take a photograph of you to keep for our records. This is important, as it helps us id and reduces fraud of both your identity and your insurance information. I acknowledge that I have read and understand the Payment Policy.

Signature

Printed Name

Date

As required by the Privacy Regulations, I hereby acknowledge that I have read a current copy of the practice's Notice Practices (7/2003 version). As required by the Privacy Regulations, I am aware that this practice reserves the right to c terms of its notice and to make new notice provisions effective for all protected health information that it maintains. I un that this office may change their Notice of Privacy Policies and is not required to honor the terms of the original/previou I agree to the Notice of Privacy Practices

Signature

Printed Name

Date

Please rate our services on yahoo.com or yelp.com. You can also send us a review on www.myhappytooth.com 2014

£ 0 Please provide us with updated phone numbers at which you can be reached. We ask this as there times during which we may need to get a hold of you to reschedule an appointment or to let you know th case is ready for delivery. We do not sell or give out any of our patient's information. That is illega medical field. Patient's Name:

Address change: Emergency Contact.

Phone

80 Please provide us with updated medications and allergies. We may ask this question at each appointments. We want to make sure that what you are taking is safe if given in conjunction with anest prescription medication you may receive from our office. MEDICATION

DOSAGE

SINCE WHEN?

REASON

Allergies:

so Please list any persons with whom it would be safe for us to share your treatment history and information with. For example, a spouse, parent, physician or other dentist. Please understand that unl person is specified we cannot disclose any treatment information without your permission. If a si presents itself where another person speaks to us on your behalf and the name is not listed, we are b law to keep your records in confidence until we speak to you first. NAME RELATIONSHIP

K)

Please provide us with updated dental insurance coverage.

Primary Dental Insurance

Secondary/Additional Dental Insurance

Dental Insurance

Dental Insurance

Company

Company

Name of Insured/Policy holder

Name of Insured/Policy holder

Member ID/SSN

Member ID/SSN

Employee Date of Birth_

Employee Date of Birth_

Employer

Employer

Please check one of the statements below: I have no other insurance policy other than with n

Dental Insurance.

I have dual insurance policies and have given all policy information to Happy Tooth. Please rate our services on yahoo.com or yelp.com. You can also send us a review on www.myhappytooth.com 2014