PATIENT FORMS. Patient Information. Responsible Party. Referral Information. Name: Birth Date: Social Security #: Home Phone: Cell Phone:

Transcription

1 PATIENT FORMS Patient Information Name: Birth Date: Social Security #: Home Phone: Cell Phone: Address: City: State: Zip: Responsible Party Name of person responsible for this account: Relationship to patient: Address: City: State: Zip: Phone: Birth Date: Drivers License #: Social Security #: Employer: Work Phone: Referral Information Were you referred by one of our patients? If yes, whom may we thank? If no, how did you find us? 1

2 Insurance Information Name of insured: Birth Date: Social Security #: Relationship to patient: Insurance Company Name: Policy Number: Secondary Insurance Information Name of insured: Birth Date: Social Security #: Relationship to patient: Insurance Company Name: Policy Number: Authorization All of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize HealthDent to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to HealthDent. I permit a copy of this authorization to be used in place of the original. Signature: Date: HIPAA Acknowledgement I have read and been offered a copy* of the HealthDent Dental Notice of Privacy Practices *copy of HIPAA Notice of Privacy Practices attached at the end of this document Signature: Date: 2

3 X Rays Would you like us to request X rays from a previous dental office? Doctor s office: Phone: Health History Your physician: Office Phone: Date of last exam: Are you under medical treatment right now? Have you ever been hospitalized for any surgical operation or serious illness? Are you taking any medications? If yes, what medications are you taking? Please list: Have you ever been prescribed antibiotics prior to dental treatment? Are you taking or have you taken Bisphosphonate drugs? (i.e.: Fosamax, Actonel, Boniva) Have you ever taken phen phen? Do you smoke/chew tobacco? If yes, how much or how often? 3

4 Are you pregnant? If yes, when are you due? Are you allergic to or had any reactions to the following? Local Anesthetics Penicillin or other antibiotics Codeine Latex (Rubber) Other: Do you or have you had any of the following? Heart Disease Rheumatic Fever Cancer Cardiac Pacemaker Asthma Arthritis Heart Murmur/MVP Emphysema Hepatitis Angina Tuberculosis High Blood Pressure Fainting/Seizures/Epilepsy Alzheimer's Prolonged Bleeding Aids/HIV Infection Anemia Diabetes Stroke Joint Replacement/Implant Kidney Disease Sexual Transmitted Disease Thyroid Problem Cold Sores/Fever Blisters History of Substance Abuse Allergies/Sinus Issues Taking Blood Thinners Other? Please note: Patient Dental History Do your gums bleed while you are brushing or flossing? Are your teeth sensitive to hot or cold liquids/ foods? 4

5 Do you have or have you had gum disease? Do you feel pain to any of your teeth? Have you ever experienced any of the following problems with your jaw? a. Do you clench or grind your teeth? b. Clicking or popping? c. Pain (joint, ear, side of face)? d. Difficulty chewing? e. Do you have frequent headaches? Do you have difficulty getting numbed? Are you apprehensive of dental treatment? Have you ever had any prolonged bleeding following extraction? Would you be interested in whitening your teeth? Do you like the appearance of your teeth/smile? If no, please explain: 5

6 Is there a particular issue or problem you are having that you want to discuss with the Doctor? (i.e.: Bad Breath, Missing Teeth, Straightening Teeth) What would you like to discuss? When was your last exam and cleaning done? Date: Signature: Date: Gum Disease At HealthDent Dental we care not only for your teeth but for your overall health as well. Gum disease has been linked with an increased risk for many chronic diseases. Eliminating gum disease is especially important to the oral and overall health of the following patients. Please take a moment to review the following and respond to those that apply to you. Tobacco User Tobacco users are more likely to develop gum disease which is more severe and more difficult to eradicate. Gum disease itself has recently been linked with an increased risk for heart disease. Since tobacco users are already at an increased risk for heart disease (and since gum disease only worsens that risk) it is vitally important for tobacco users to do whatever is necessary to eliminate gum disease. Current Tobacco user What form? (cig, pipe, chew, etc.) How much/day? For how long? Previous Tobacco user When did you quit? Date: 6

7 Diabetes Diabetes is a well known risk factor for gum disease. Research is confirming that when left untreated gum disease makes it harder for you to control your blood sugar. Elimination of gum disease can improve your blood sugar control reducing your risk for the serious complications. How is your diabetes control? Good Fair Poor How much/day? For how long? Date of last A1c: What Score? Who is your diabetes doctor? Family History of Gum Disease Some people are genetically prone to developing gum disease even if they decent care of their mouths. Do you have any family history of gum disease? Stress Stress is a well known risk factor for gum disease. Is your stress level too high? Life altering events (loss of jobs, divorce, death in family, moving to new location, etc.) can be particularly strong factors for gum disease. Are you currently going through any life altering events? Rheumatoid Arthritis There is a bi directional connection between rheumatoid arthritis. If you have arthritis you are at an increased risk for gum disease. Emerging research suggests that eliminating any gum disease and then keeping it at bay can lessen the crippling effects of arthritis. Have you ever been diagnosed with Rheumatoid Arthritis? 7

8 Overweight Being overweight is now recognized as a strong risk factor for gum disease. Obesity and gum disease are both risk factors for heart disease and diabetes. Thus, if you are over your ideal weight, it is vitally important for you to eliminate any gum inflammation to lower your risks for more serious health problems. List your current weight: List your current height: BMI = (703 x weight)/(height x height) 18.4 or below Underweight 18.5 to 24.9 Healthy Weight 25.0 to 29.9 Overweight Obese Oral Cancer Screening At HealthDent Dental, we continually look for advances to ensure that we are providing the optimum level of oral healthcare to our patients. We are concerned about oral cancer and look for it in every patient. One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause of increasing incidence and mortality rates of oral cancer. As with most cancers, age is the primary risk factor for oral cancer. Tobacco and alcohol use are other major predisposing risk factors, but more than 25% of oral cancer victims have no such lifestyle risk factors. Studies also suggest that human papillomavirus (HPV 16/18) plays a role in more than 20% of oral cancer cases. Oral cancer risk by patient profile is as follows: INCREASED RISK: Patients age 18 39, sexually active patients (HPV 16/18) HIGH RISK: Patients age 40 and older, tobacco users (ages 18 39, any type within 10 years) HIGHEST RISK: Patients age 40 and older with lifestyle risk factors (tobacco and/or alcohol use); previous history of oral cancer For these reasons, we will always perform a cancer screening during your appointment at no extra cost to you. Signature: Date: 8

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