Health History Form s1

Little House Dentristy Patient Information Welcome to our office! To assist us in serving you, please complete the following confidential form.

Patient's name ______Preferred name ______Birth date______Home phone ______Cell phone ______Email ______Perrefed method of contact ______Mailing address ______City ______State ______Zip ______Employer ______Occupation ______Emergency contact name ______Emergency contact number______Relationship______Whom may we thank for referring you to our office? ______

INSURANCE INFORMATION:  Not covered by dental insurance Social Security number: ______Dental Insurance Co.______Group #______ID #______Are you the insurance subscriber?  yes  no If no, relationship to subscriber ______Insurance Subscriber’s birth date ______Subscriber’s Social Security number ______

MEDICAL HEALTH HISTORY

(PLEASE CHECK ANY THAT APPLY)

Heart problems  Heart attack Date: ______ History of heart surgery Date:______Tobacco use  High Blood pressure  Smoking frequency______ Heart murmur  Smokeless frequency______ Heart valve problem  Past use and approximate quit date ______ Rheumatic fever  Pacemaker Do any of the following apply?  Type I or type II diabetes Bone or joint problems  Family history of diabetes  Arthritis  Stroke Date: ______ Joint Replacement Date: ______ History of drug or alcohol abuse  Fainting spells, seizures or epilepsy Has a physician recommended antibiotic  Respiratory disease (tuberculosis, COPD, other ) premedication for your dental appointments?  yes  Hepatitis, jaundice or liver trouble  no  Thyroid problems  Cancer or tumor Blood problems  Pregnant  Easy bruising  Nursing  Abnormal bleeding  Blood disease Allergies  Blood transfusion Are you allergic to, or have you reacted adversely to any of  HIV-positive/AIDS the following?   Penicillin, sulfa, or other antibiotics Allergy problems  Local anesthetics ("Novacaine")  Hay fever / Asthma  Codeine or other narcotics  Sinus problems  Barbiturates, sedatives or sleeping pills  Skin rashes  Aspirin, Acetaminophen or Ibuprofen  Taking allergy medication  Metals  Latex Intestinal problems  Other:______ Ulcers  Special diet ______How are you feeling today?  Constipation or diarrhea ______Date______

List of current medications and those taken within the last year ______

Name and phone number of your physician:______

DENTAL HEALTH HISTORY

How long has it been since your last cleaning and exam? Are your teeth sensitive to any of the following? ______Hot  yes  no How often do you brush? ______Cold  yes  no How often do you floss? ______Sweets  yes  no Do you have a dry mouth? Pressure  yes  no  yes  no Do you have airway/sleep issues or have you been Are you apprehensive about dental treatment? diagnosed with sleep apnea?  yes  no  yes  no Have you had problems with previous dental treatment? Do you snore?  yes  no  yes  no Are you satisfied with the appearance of your teeth? Do you wear a night guard?  yes  no  yes  no Do you avoid brushing part of your mouth due to pain? Are you aware of an uncomfortable bite?  yes  no  yes  no Do you gag easily? Have you had a blow to the jaw (trauma)?  yes  no  yes  no Do you wear dentures or partials? Do you have any jaw symptoms or headaches upon waking  yes  no up in the morning? Do you have difficulty chewing or chew only on one side of  yes  no your mouth? Do you have pain in the face, ear, jaws, joints, throat, neck  yes  no or temples? Do your gums feel swollen, tender or bleed?  yes  no  yes  no Do you have difficulty opening your mouth? Have you noticed swelling, lumps or sores in your mouth?  yes  no  yes  no Does your jaw make noise when eating or opening?  yes  no Do you clench or grind your teeth?  yes  no

Signature of patient or guardian ______Date ______Dr. Signature ______Date ______

Little House Dentistry

Financial Agreement

Our goal is to provide the highest quality of dental care possible and to have clear communication of our financial policy.

Patient with insurance: The patient is responsible for estimated copayment on procedures and/or deductible at the time of the service. After insurance has responded, any unpaid amount will be billed directly to the patient.

Patients without insurance: Payment is due at the time of service.

Payment options:  Cash  Check  Credit card  Care Credit

Acknowledgement of Receipt of HIPAA Notice of Privacy Practices Please Note: It is your right to refuse to sign this Acknowledgement.

I acknowledge that I have received a copy of this Dental Practice's HIPAA Notice of Privacy Practices.

______Patient name (please print)

______Patient signature

______Date

Preferred contact method: (Please circle one)  Phone  Text (coming soon!)  Email