Patient information Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. lf there have been any changes in your health, please tell us. If you have any questions, please don't hesitate to ask. Patient name Today's date Date of birth Age Gender How did you hear about us? Personal Referral Doctor Referral Insurance Referral Facebook Google Other Driver's license number State Home address Phone Cell Phone Email address Billing address (if different from above) Employer/occupation Business phone Spouse's name Spouse's phone Emergency contact and phone (other than spouse) Primary dental insurance Group number Secondary dental insurance Group number Subscriber's name Subscriber's insurance number Date of birth Age Sex Name of your medical doctor Date of last visit to medical doctor Name of previous dentist Date of last visit to dentist Referred to us by Dental Health History Do you have or have you had any of the following? (check all the apply) Apprehension about dental treatment Problems with previous dental treatment Gag easily Wear dentures Food catches between your teeth Difficulty chewing your food Chew on only one side of your mouth Avoid brushing any part of your mouth because of pain Gums bleed easily Gums bleed when flossing Gums feel swollen or tender Notice slow-healing sores in or around your mouth Feel twinges of pain when your teeth come into contact with: Hot foods or liquids Cold foods or liquids Sour foods Sweet foods Take fluoride supplements Feel dissatisfied with the appearance of your teeth? Want to save your teeth? Want complete dental care? How often do you brush? How often to you floss? Your jaw makes noise so that it bothers you Or others Clench or grind your teeth frequently Jaws feel tired Jaw gets stuck so that you can't open freely Pain when you chew or open wide to take a bite Earaches or pain in front of your ears Jaw symptoms or headaches upon awaking in the morning Jaw pain or discomfort affecting your appetite, sleep, daily routine, or other activities Jaw pain or discomfort that is extremely frustrating or depressing Take medications for pain or discomfort (pain relievers, muscle relaxants, antidepressants) Temporomandibular (jaw) disorder (TMD) Pain in the face, cheek, jaws, joints, throat, or temples Unable to open your mouth as far as you want Aware of an uncomfortable bite Had a blow to the jaw (trauma) Habitually chew gum? Smoke? Pipe? Other? Use chewing tobacco? Medical Health History Do you have or have you had any of the following? (check all that apply) Heart problems Chest pain Shortness of breath Blood pressure problem Heart murmur Heart valve problem Taking heart medication Rheumatic fever Pacemaker Artificial heart valve Blood problems Easy bruising Frequent nosebleed/abnormal bleeding Blood disease Anemia Ever require a blood transfusion? Allergy problems Hay fever Sinus problems Taking allergy medication Asthma Intestinal problems Ulcers Weight gain or loss Special diet Constipation/diarrhea Kidney or bladder problems Fainting spells, seizures or epilepsy Stroke(s) Frequent or severe headaches Thyroid problems Persistent cough or swollen glands Pre-medications required by physician Cancer/tumor Diabetes Urinate more than six times a day Thirsty or mouth is dry much of the time Family history of diabetes Tuberculosis or other respiratory disease Bone or joint problems Arthritis Back or neck pain Joint replacement (e.g. hip, pins, implants) Drink alcohol or use recreational drugs? lf so, how much? Hepatitis,jaundice or liver trouble Herpes or other STD HIV positive/AIDS Glaucoma Do you wear contact lenses? Head injury Epilepsy or other neurologic disease History of alcohol or drug abuse During the past 12 months, have you taken any of the following? Antibiotics or sulfa drugs Anticoagulants (e.g. Coumadin) High blood pressure medicine Tranquilizers Insulin, Tolbutamide or similar drug Aspirin Digitalis or drugs for heart trouble Nitroglycerin Cortisone (steroids) Natural remedies Nonprescription drug/supplements Other Are you allergic or have you reacted adversely to any of the following? Local anesthetics (Novocain) Penicillin or other antibiotics Sulfa drugs Barbiturates, sedatives or sleeping pills Aspirin, acetaminophen or ibuprofen Codeine, Demerol or other narcotics Metals Latex or rubber dam Other What medications are you currently taking? taking? Women Are you taking contraceptives or other hormones? Are you pregnant? If so, expected delivery date Are you nursing? Have you reached menopause? If so, do you have symptoms? Other disease, condition or problem not listed above: Patient signature/legally authorized representative and relations Doctor signature______________________ Date Date______________________ PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY NOT BEUSED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT CAREFULLY. Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by usin one or more of the following respects: To other health care providers (i.e., your generaldentist, oral surgeon, etc.) in connection with our rendering periodical treatment to you (i.e., to determine the results of restorations, surgery, orthodontic treatment, etc.); To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payments, etc.) To certifying, licensing and accrediting bodies (i.e., the American Board of Periodontology, state dental boards, etc.) in connection with obtaining certification, licensure oraccreditation; Internally, to all staff members who have any role in your treatment; To other patients and third parties who may see or over hear incidental disclosures about your treatment, scheduling, etc.; To your family and close friends involved in your treatment; and/or, We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke. Under the new privacy rules, you have the right to: Request restrictions on the use and disclosure of your protected health information; Request confidential communication of your protected health information; Inspect and obtain copies of your protected health information through asking us; Amend or modify your protected health information in certain circumstances; Receive an accounting of certain disclosures made by us or your protected health information; and, You may, without risk of retaliation, file acomplaint as to any violation by us of your privacy rights to us (by submitting inquires to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must befiled within 180 days of the violation). We have the following duties under the privacy rules: By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information; To abide by the terms of our Privacy Notice that is currently in effect; To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all projected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice. Please notes that we are not-obligated to: Honor any request by you to restrict the use or disclosure of your protected health information; Amend your protected health information if, for example, it is accurate and complete; or Provide an atmosphere that is totally free ofthe possibility that your protected health information may be incidentally overhead by other patients and third parties. This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask our Privacy Contact Person or direct your questions to this person at our office. Thank you. PATIENT ACKNOWLEDGEMENT I hereby acknowledge that I have received and reviewed a copy of this Privacy Notice. Patient Signature Date Please enter code above in the field below.