DENTAL HEALTH HISTORY

Transcription

1 , 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. If there have been any changes in your health, please tell us. If you have any questions, don 't hesitate to ask. Patient name: Date of birth: Sex: Age: Home address: City: State: Billing address (if different): City: State: Zip: Home phone: Cel SS #: Employer/Occupation: Bus. Phone: Spouse's name & phone #:_ Emergency phone # (other than spouse): Primary dental insurance:_ Group #: Secondary dental insurance: Group #: Subscriber's name: Date of birth: SS #: Name of your medical doctor: Name of previous dentist: Date of last visit to medical doctor: Date of last visit to dentist: Referred to us by: DENTAL HEALTH HISTORY Yes No Yes No Are you apprehensive about dental treatment? Have you had problems with previous dental treatment? Do you gag easily? How often do you brush? How often do you floss? Does your jaw make noise so that it bothers you Do you wear dentures? Does food catch between your teeth? Do you have difficulty in chewing your food? Do you chew on only one side of your mouth? Do you avoid brushing any part of your mouth because of pain? Do your gums bleed easily? Do your gums bleed when you floss? Do your gums feel swollen or tender?. II Do you clench or grind your jaws frequently? Do your jaws ever feel tired? Does your jaw get stuck so that you can't open freely? Does it hurt when you chew or open wide to take a bite? Do you have earaches or pain in front of the ears? Do you have any jaw symptoms or headaches upon awaking in the morningl Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities? Have you ever noticed slowhealing sores in or Do you find jaw pain or discomfort extremely about your mouth?.... frustrating or depressing?.... Are your teeth sensitive? Do you feel twinges of pain when your teeth come in contact with: Hot foods or liquids? Cold foods or liquids? Sours?._ Sweets?.. Do you take fluoride supplements? Are you dissatisfied with the appearance of your teeth? Do you prefer to save your teeth? Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)? Do you have a temporomandibular (jaw) disorder (TMD)? Do you have pain in the face, cheeks, jaws, joints, throat, or temples?. Are you unable to open your mouth as far as you want? Are you aware of an uncomfortable bite? Have you had a blow to the jaw (trauma)l Do you want complete dental care? Are you a habitual gum chewer or pipe smoker?..

2 MEDICAL HEALTH HISTORY: Do you have, or have you had, any of the following? Yes No Yes No Heart Problems._IJ Diabetes El LI Chest pain LI Urinate more than 6 times a day El El Shortness of breath [ii. LI Thirsty or mouth is dry much of the time LI El Blood pressure problem LI Family history of diabetes El LI Heart murmur LI LI Heart valve problem Tuberculosis or other respiratory disease Taking heart medication LI LI Do you drink alcohol? Ii] LI Rheumatic fever LI [1 If so, how much? Pacemaker [1 [1 Do you smoke? Artificial heart valve F 1 ri If so, how much? Blood Problems._ L._l Hepatitis, jaundice, or liver trouble H H El El Easy bruising Frequent nosebleeds H H Herpes or other STD H Abnormal bleeding H H HIVpositive/AIDS Blood disease (anemia) H H Ever require a blood transfusion? H H Glaucoma Allergy Problems. LI LI Do you wear contact lenses? III LI Hay fever LI LI History of head injury? 1 Sinus problems LI LI Epilepsy or other neurological disease? Skin rashes LI LI Taking allergy medication H H History of alcohol or drug abuse?.. Jill Asthma._ H H Do you have any disease, condition, or problem not listed Intestinal Problems [7 previously that you feel we should know about? Ulcers If so, please describe: Weight gain or loss LI LI Special diet LI Constipation/Diarrhea LI LI During the past 12 months, have you taken Kidney or bladder problems LI LI any of the following? Yes No Bone or Joint Problems H Antibiotics or sulfa drugs Arthritis LI] H Anticoagulants (e.g., Coumadin) Back or neck pain LI LI High blood pressure medicine Joint replacement. L C. Tranquilizers (e.g., total hip, pins, or implants) Insulin, Orinase, or similar drug Fainting Spells, Seizures, or Epilepsy Aspirin Stroke(s) I. Digitalis or drugs for heart trouble Nitroglycerin Frequent or severe headaches LI Cortisone (steroids) Thyroid problems H H Persistent cough or swollen glands LI LI Other Natural remedies Nonprescription drug/supplements Premedications required by physician H H..... Cancer/Tumor.. LI LI Women ye'; No Are you allergic, or have you reacted adversely, Are you taking contraceptives or to any of the following? Yes No other hormones? Local anesthetics ("Novocaine") Penicillin or other antibiotics Sulfa drugs Barbiturates, sedatives, or sleeping pills Aspirin, Acetaminophen, or Ibuprofen Codeine, Demerol, or other narcotics Reaction to metals Latex or rubber darn Other Are you pregnant? If so, expected delivery date: Are you nursing? Have you reached menopause? If so, do you have any symptoms?. Notes: Date: Patient/Parent Signatur

3 DENTAL TREATMENT CONSENT FORM Dentist's Name Patient's Name: Please read and initial the items checked below and read and sign at the bottom of form. i. XRAYS (Initials 2. DRUGS AND MEDICATIONS I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). (Initials 3. CHANGES IN TREATMENT PLAN I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary. (Initials II 4. REMOVAL OF TEETH Alternatives to removal have been explained to me (root canal therapy, crowns, and periodontal surgery, etc.) and I authorize the Dentist to remove the following teeth and any others necessary for reasons in paragraph #3. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility. (Initials 5. CROWNS, BRIDGES AND CAPS I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit. size and color) will be before cementation. (Initials 6. DENTURES, COMPLETE OR PARTIAL I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these appliances have been explained to me, including looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new dentures (including shape, fit, size, placement, and color) will be the "teeth in wax" tryin visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee. (Initials 7. ENDODONTIC TREATMENT (ROOT CANAL I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment, I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy). (Initials 8. PERIODONTAL LOSS IT I understand that care must be exercised in chewing on fillings especially during the first 24 months to avoid breakage. I understand that a more expensive filling that initially diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after effect of a newly placed filling. (Initials 9. FILLINGS I understand that care must be exercised in chewing on fillings especially during the first 24 hours to avoid breakage. I understand that a more expensive filling that initially diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after effect of a newly placed filing. (Initials U 10. DENTURES I understand the wearing of dentures is difficult. Sore spots altered speech and difficulty in eating are common problems. Immediate dentures (placement of dentures immediately after extractions) may be painful. Immediate dentures may require considerable adjusting and several relines. A permanent reline will be needed later. This is not included in the denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in poorly fixed dentures. If a remake is required due to my delays of more than 30 days there will be additional charges. (Initials I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment. Signature of Signature of Parent/Guardian if patient is a minor Date Date

4 Johnny Bear, D.D.S Wichers Dr. Unit A Marrero, LA Office (504) Fax (504) HIPPA Notice of Privacy Act For West Jefferson Dental Center Office Policy and Notice of HIPAA Privacy Practice Thank you for choosing our practice for your dental health needs. Our goal is to provide quality care to all our patients with affordable fees. We are dedicated to making healthcare less stressful and more valuable by clarifying financial responsibilities in advance. It is our office policy to bill your insurance carrier as a courtesy to you. Therefore it is your responsibility to make sure we have current insurance information for you and your family. Ultimately any remaining balance not covered by your insurance is your responsibility. Payment may be made by CHECK, CASH, VISA, MASTERCARD, DISCOVER and AMERICAN EXPRESS. If unable to pay in full we offer CARE CREDIT financing. There is a returned check fee of $25.00 for all checks returned to us by the bank for insufficient funds. Our office will be happy to make arrangements in advance of service for extensive dental treatment. Our office however, will charge for a broken or no show appointment with less than 48 hour notice and will require a deposit on the rescheduled appointments. This notice of Privacy Practice describes how we as health care providers may use and disclose your protected information to carry out treatment, payment and health care operations and for other purposes that are permitted or required by law. Protected Health Information (PHI) is information about you, including demographic information. That may identify you and that relates to your past, present and future physical or mental health or condition and related to health care services. The Department of Health and Human Services has established a "Privacy Policy" to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients' consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to assure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.

5 Johnny Bear, D.O.S Wichers Dr. Unit A Marrero, LA Office (504) Fax (504) We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer. Patent Signature: Date: Office Witness: Date:

6 Appointment Guidelines and Agreement Since providing quality treatment for all of our patients in a timely matter is a major focus in our practice philosophy, we would like to clarify our appointment guidelines with you and ask that you assist us in this endeavor. There will be absolutely no charge for your need to reschedule an appointment provided you give us 48 hour notice and you contact us during business hours. This would allow us to give this time to another patient who is in need and waiting for an appointment. Not showing for 3 appointments will result in a reservation fee being required to reserve time in our schedule for future appointments Last Minute cancellations can cause hardships for many individuals. So as a result of last minute cancellations, there will be a $25.00 fee. It is our last sincere hope that you will accept these guidelines and join us in our efforts to provide quality time for you and each valued patient in our practice. Thank You Kindly (Patient) (Date)