Health History Form

Patient Information

( This information is necessary for our files and will be considered CONFIDENTIAL)

Patient's Name Last

First

Initial

Age

Patient's Birthday

Male Female

If patient is a minor, give name of patient or legal guardian

Relationship

Residence Address Street

City

Zip

For how long?

Own Rent

Patient is:
Married
Single
Divorced
Separated
Widowed
Minor

Driver’s License No.

Social Security No.

Resp. Phone

What is your main concern about your smile or bite?

Cell Phone

Employed by

How long?

Occupation

Business Address Street

City

Zip

Bus. Phone

Spouse's Name

Driver's Licence No.

Soc. Sec. No.

Employed by

How long?

Occupation

Business Address Street

City

Zip

Bus. Phone

Name of nearest relative not living with you

Realtionship

Complete Address Street

City

Zip

Res. Phone

I have no physician

Name of Physician Address

City

Telephone

Name of Current Dentist/Orthodontist Address

City

Telephone

What is your primary concern about your teeth?

Expectations for this Appointment?

Do you wish to speak to the doctor privately? Yes No

Is this visit for Emergency Orthodontic Care Yes No

If yes, explain:

School Children Attend

Whom may we thank for referring you?

Financial Information

Person responsible for this account

Relationship

Telephone

Address Street

City

Zip

Cell Phone

Name of insurance company (primary insurance)

Insured's person name

Birth date

Relationship

Social security no.

Name of group dental plan

Group No.

Plan No.

Name of union

Local

Name of insurance company (secondary insurance)

Insured's person name

Birth date

Relationship

Social security no.

Name of group dental plan

Group No.

Plan No.

Name of union

Local

Terms and Condition

As a condition of treatment by this office, I understand financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency orthodontic services, or any orthodontic service performed without prior financial arrangements, must be paid for in cash at the time services are performed. I understand that orthodontic services furnished to me are charged directly to me and that I am personally responsible for payment of all orthodontic services. I carry insurance, I understand that this office will help prepare my insurance forms to assist in making collections from my insurance companies and will credit such collections to my account. However, AO cannot render services on the assumption that charges will be paid by an insurance company.

Assignment of Insurance: I hereby authorize my insurance company to pay directly to my Orthodontist benefits accruing to me under my policy. A bookkeeping fee of $50/month will be charged on the unpaid principal balance on all accounts not paid within 30 days of treatment date. I understand that the fee estimate listed for this orthodontic service can only be extended for a period of six months from the date of the patient’s examination. In consideration of the professional services rendered to me, or at my request , by the Doctor and/or by his staff, I agree to pay, therefore, the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I furthermore agree that the reasonable value or said services shall be billed unless objected to by me, in writing, within the time of paying thereof. Additionally, I agree that a waiver for any breach of any term or condition hereunder shall not constitute a waiver of any further term or condition. I further agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred including reasonable attorney’s and/or collection fees.

I have read the above conditions of treatment and agree to their content.

Signature

Date

Health Questionnaire

These questions are for your benefit and assure that treatment will take into consideration your past and present health status. Some questions may seem unrelated to your orthodontic condition, but they are all associated with proper oral health care.
Please answer each question. Check the appropriate box and/or circle YES or No where applicable.

Medical History

1. Are you in good health?

Yes No

2. Date of last physical examination

3. Are you now under the care of a physician?

Yes No

If so, what is the condition being treated?

4. Have you ever had any serious illness or operation?

Yes No

If so, what illness or operation?

5. Have you ever been hospitalized?

Yes No

If so, what was the problem?

6. Are you taking any

medication, drugs or herbs?

Yes No

If so, what?

What dosage?

7. Are you using any recreational drugs (marijuana, cocaine, etc.)? Yes No

If so, what?

8. Have you ever been pre medicated with antibiotics for your dental treatment?

Yes No

9. Are you sensitive or allergic to any drugs or materials?

Yes No

Penicilin,
Tetracycline
Sulfa Drugs
Aspirin
Codeine
Latex
Other

10. Do you have or have you had any of the following: (Please circle 'Y' for Yes or 'N' for No - answer all conditions):

Y N

Snoring

Y N

Sleep Apnea

Y N

Anemia

Y N

Herpes

Y N

Stroke

Y N

Ulcers

Y N

Diabetes

Y N

Arthritis

Y N

Asthma

Y N

Cancer

Y N

Seizures

Y N

Hay Fever

Y N

Headaches

Y N

Implant (s)

Y N

Glaucoma

Y N

Tonsillitis

Y N

Hemophilia

Y N

Cold Sores

Y N

Emphysema

Y N

Rheumatism

Y N

Chicken Pox

Y N

Bruise Easily

Y N

Head Injuries

Y N

Heart Failure

Y N

Scariel Fever

Y N

Sinus Trouble

Y N

Heart Murmur

Y N

Blood Disease

Y N

Heart Ailments

Y N

Heart Attack

Y N

Cerebral Palsy

Y N

Drug Addiction

Y N

Kidney Disease

Y N

Chemotherapy

Y N

Stomach Ulcers

Y N

Angina Pectoris

Y N

Mental Disorder

Y N

Thyroid Disease

Y N

Fainting Spells

Y N

Rheumatic Fever

Y N

Tuberculosis (T.B.)

Y N

Blood Transfusion

Y N

Low Blood Sugar

Y N

Joint Replacement

Y N

Nervous Disorders

Y N

Tumors or Growths

Y N

Allergies or Hives

Y N

Pain in Jaw Joints

Y N

Artificial Prosthesis

Y N

Sickle Cell Disease

Y N

Cortisone Medicine

Y N

Allergies to Metals

Y N

Excessive Bleeding

Y N

Mitral Valve Prolapse

Y N

High Blood Pressure

Y N

Low Blood Pressure

Y N

HIV Related Complex

Y N

Respiratory Disease

Y N

Epileosy or Seizures

Y N

Psychiatric Treatment

Y N

Hepatitis or Jaundice

Y N

Difficulty Swallowing

Y N

Congenital Heart Lesions

Y N

Osteoporosis

Y N

X-Ray or Cobalt Treatment

Y N

Radiation Treatment of any kind

Y N

Venereal Disease (Syphilis, Gonorrhea)

Y N

Acquired Immune Deficiency Syndrame (AIDS)

Y N

TMJ (Temporomandibular Joint) Disorder

Y N

Other

11. Do you have any disease, condition or problem not listed that you think we should know about?

Yes No

If so, what?

12. Do you wear a cardiac pacemaker, or have you had heart surgery?

Yes No

13. Do you smoke? If yes, how much?

Cigarettes, Cigars Packs per day

Yes No

14. Have you ever taken the drugs?

Yes No

Fen-phen,
Redux,
Fosamax(Bisphosphonate),
Zometa,
Actonel,
Boniva,
Aredia,
Diet Drugs?

15. (Women) Are you pregnant? If so how many months?

Yes No

16. (Women) Do you have any problems associated with your menstrual period?

Yes No

17. (Women) Do you take any birth control medication and hormones?

Yes No

Dental History

1. Have you ever had Orthodontic Treatment? ...if so, Date?

Yes No

2. Have you ever been recommended Orthodontic Treatment? ...if so by whom?

Yes No

3. Have you completed all your dental work? or is there more work planned for the future?

Yes No

If so, explain?

4. How long since your last full mouth X-Rays?

Weeks

Months

Years

5. How long since your last dental treatment?

Weeks

Months

Years

6. Does dental treatment make you nervous?

Slightly, Moderately Extremely

Yes No

7. Are you currently wearing any dental removeable devices? ...if so, Explain ?

Yes No

8. What is it about your smile you would like to improve?

I hereby acknowledge I have received a copy of this practice's NOTICE OF PRIVACY PRACTICES. I further understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified, or changes in any way.

Patient refused / was unable to sign because:

I have received a copy of the Dental Materials Fact Sheet as required by law.

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or if my medications change, I will, without fail, inform the doctor at my next appointment.

Date

Signature

Reviewed by

Lic #

Date

B UPDATE - Since your last visit A :

1. Have you seen a medical doctor?

Yes No

2. Have you had a change in your medication?

Yes No

3. Have you had a change in your medical condition or had surgery?

Yes No

Please note changes in health since last visit. If no changes, please write "None"

Date

Signature

C UPDATE - Since your last visit B :

4. Have you seen a medical doctor?

Yes No

5. Have you had a change in your medication?

Yes No

6. Have you had a change in your medical condition or had surgery?

Yes No

Please note changes in health since last visit. If no changes, please write "None"

Date

Signature

REVIEWED BY

Date

DO NOT WRITE IN THIS SPACE

DATE

B.P

PULSE

TEMP

DATE

HEALTH QUESTIONNAIRE MUST BE CONTINUALLY UPDATED!

CONSENT FOR TREATMENT: I hereby grant authority to the dentist(s) in charge of the care of the patient whose name appears on this Health History form, to administer such anesthetics, analgesics, sedatives, nitrous oxide sedation and intravenous sedation; and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient. I have been informed of all possible complications of the procedures, anesthetics and/or drugs.

All services are rendered and accepted under the terms and conditions printed on the reverse here of:

Authorization must be signed by the patient, or by the nearest relative in the case of a minor or when the patient is physically or mentally incompetent.

Signed

Date

Relationship to patient