Health History Form



Mark T. Hanstein, DDS

Creating Beautiful Smiles

Patient Information

Welcome! To provide you with the best dental care, please complete the following confidential form.

The information provided is important to your oral health.

Patient's name ____________________________________________ Preferred name ________________________ Birth date

If minor, parents names _____________________________________ Home phone Cell phone

Social Security #___________________________________________ Email Address Preferred method of contact θ Home θ Work θ Cell θ Email

Mailing address __________________________________________________________ City __________________ State ________ Zip ___________

Employer ______________________________________ Occupation _______________________________________________________________

Spouse's name ___________________________________ Spouse's employer _________________________________ Spouse’s Date of Birth

Whom may we thank for referring you ? _______________________________________________________________________________________________

Person to contact in case of emergency ______________________________________________________________ Phone _____________________________

Responsible Party

Name of person responsible for this account _____________________________________________________ Relationship to patient_____________________

Address______________________________________________________________________________________ Home phone _________________________

Responsible Party’s Social security# ____________________________________________________ Date of Birth ____________________________________

Employer _________________________________________________ Work Phone __________________________ Cell phone _________________________

Insurance information

θ NOT COVERED BY DENTAL INSURANCE

Name of Insured ______________________________________________________________ Relationship to patient ____________________________________

Insured Birthdate ____________________________ Insured SS# _______________________________ Member ID # __________________________________

Dental Insurance Company ________________________________________ Ins. Phone # _____________________________ Group # ____________________

Secondary Insurance Information

Name of Insured ______________________________________________________________ Relationship to patient ____________________________________

Insured Birthdate ____________________________ Insured SS# _______________________________ Member ID # __________________________________

Dental Insurance Company ________________________________________ Ins. Phone # _____________________________ Group # ____________________

Medical Health History

Do you have or have you had any of the following? (Please check any that apply)

❑ Are you required to Pre-medicate before any dental treatment?

Cancer:

❑ Type:

❑ Chemotherapy

❑ Radiation Therapy

Cardiovascular:

❑ Angina (chest pain)

❑ Artificial Heart Valve

❑ Heart conditions

❑ Heart Surgery

❑ High/Low Blood Pressure

❑ Mitral Valve Prolapse

❑ Pacemaker

❑ Rheumatic Fever

❑ Scarlet Fever

❑ Stroke

Endocrinology:

❑ Diabetes

❑ Hepatitis A/B/C

❑ Jaundice

❑ Kidney Disease

❑ Liver Disease

❑ Thyroid Disease

Gastrointestinal:

❑ Ulcers (Stomach)

❑ Gastrointestinal Disease

Hematologic/Lymphatic:

❑ Anemia

❑ Blood Disorders

❑ Bruise Easily

❑ Excessive Bleeding

Musculoskeletal :

❑ Arthritis

❑ Artificial Joints

❑ Jaw Joint Pain

❑ Rheumatoid Arthritis

Neurological:

❑ Anxiety

❑ Depression

❑ Dizziness

❑ Drug/Alcohol Addiction

❑ Fainting

❑ Seizures

❑ Psychiatric Illness

Respiratory:

❑ Asthma

❑ Emphysema

❑ Respiratory Problems

❑ Sinus Problems

❑ Sleep Apnea

❑ Tuberculosis

Viral Infections:

❑ AIDS

❑ HIV Positive

❑ HPV

Women:

❑ Currently Pregnant

❑ Nursing

❑ Pregnant or may be pregnant

Expected Delivery date:

Medical Allergies:

❑ Antibiotics

(Penicillin/Amoxicillin/Clindamycin)

❑ Opioids

(Percocet, Oxycodone, Tylenol 3)

❑ Latex

❑ Local Anesthetics

❑ NSAIDs

❑ List of Medicines: ________________________________________________ ________________________________________________________________________

Do you have any disease, condition, or problem not listed above?________________________________________________

Dental History:

Appearance:

❑ Discolored teeth

❑ Worn teeth

❑ Misshaped teeth

❑ Crooked teeth

❑ Spaces

❑ Overbite

❑ Flat teeth

Pain/Discomfort:

❑ Sensitivity (hot,cold,sweet)

❑ Pressure

❑ Broken teeth/fillings

❑ Worn teeth

❑ Dry mouth

Function:

❑ Grinding/Clinching

❑ Headaches

❑ Jaw Joint (TMJ) pain

❑ Jaw Joint (TMJ) clicking/popping

❑ Bad Bite

❑ Speech Impediment

❑ Mouth Breaking

❑ Sore Muscles (neck,shoulders)

❑ Difficulty Opening or Closing

❑ Difficulty Chewing on either side

Periodontal (Gum) health:

❑ Bleeding, Swollen, Irritated gums

❑ Bad breath

❑ Loose tipped, shifting teeth

❑ Previous perio/gum disease

Habits:

❑ Thumb sucking

❑ Nail biting

❑ Cheek/Lip biting

❑ Chewing on ice/foreign objects

Sleep Patterns or Conditions:

❑ Sleep Apnea

❑ Snoring

❑ Daytime Drowsiness

❑ Bed wetting (for children)

Social:

Tobacco

How much _____ How long _____

Alcohol Frequency _____________

Drug Frequency _______________

Previous Comfort Options:

❑ Nitrous Oxide

❑ Oral Sedation (pill)

❑ IV Sedation

Please list family history of any conditions marked:

Are you under the care of a physician? Y or N, if yes please explain

Physician Name Address: Phone(___)____________

Have you had a serious illness, operation, or hospitalization in the past 5 years? Y or N, if yes please explain

Are you taking or have you recently taken any prescription or over the counter medicine(s)? Y or N, please

List all and why, including vitamins, natural or herbal supplements and/or dietary supplements

Have you ever in the past, or are you now currently taking any medications for Osteopenia/Osteoperosis or Bone Disease? If so, please list medications:

Have you ever had surgery? If so, what type:

Consent:

The undersigned hereby authorize doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand that use of anesthetic agents embodies a certain risk. I have read, understand and agree to the above terms and conditions.

_________________________ ________________________ __________ _______________________

Signature of Patient/Legal Guardian Print Name Date Dentist Signature

HIPAA Release Consent

Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invlaid and it will not be possible for your health information to be shared as requested.

Section I

I, give my permission for Mark T. Hanstein, DDS to share the information listed in Section II with the person(s) I have specified in Section III of this document.

Section II – Health Information

I would like to give the above healthcare organization permission to:

_____ Disclose my complete health record including, but not limited to, diagnoses, lab results, treatment and billing records for all conditions.

_____ Electronic copy or access via a web based portal

_____ Hard copy

Section III – Who Can Receive My Health Information

Name:

Organization:

Address:

I understand that the person(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them.

Section IV – Duration of Authorization

This authorization is valid from ______________ to ________________ OR

This Authorzation is valid from the date of the signature until the following event: __________________

Signature: ___________________________________________________ Date: ________________________

Financial & Privacy Policy

Thank you for choosing our office for your dental care needs. We are committed to your dental care needs. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy which we require you read and sign prior to any treatment.

Full payment of office copays is due at time of service. You are responsible for deductibles and coinsurance directed by your insurance policy. We accept cash, checks, visa, mastercard, and discover.

Insurance

Your office copay is due at time of your visit. For your convenience, we will file insurance claims with all insurance carriers. We are an in network provider for Health Choice, Delta Dental Premiere, and Blue Cross Blue Shield of Oklahoma. You will be responsible for any deductibles, coinsurance and any non-covered or excluded services as explained in your policy. Payment of any patient portion due after insurance is expected upon receipt of a statement. We cannot bill your insurance company unless you provide us with all correct and current information. Please make sure to have this information with you at the time of your appointment. You are responsible for notifying us of any changes in insurance coverage each visit.

Private Pay

If you do not have insurance, payment is due at time of service. We accept, cash, checks, visa, mastercard, and discover. Please be prepared to pay in full at the time of your visit unless prior arrangements have been made.

No-show policy

A $50.00 no-show fee will be charged in the event you fail to show for an appointment without contacting our office 48 hours in advance of the scheduled appointment time. Payment of the no-show fee will be required prior to escheduling any future appointments. In the case of repeated no-shows, you may be required to pre-pay a non-refundable administrative fee equal to the amount of your scheduled appointment prior to re-scheduling your next appointment. If the re-scheduled appointment is not kept, the fee will be considered a no-show charge.

________________________________________________________________________________________________________

Patient Name (print) Patient Signature Date

Acknowledgement Of Receipt Of Notice Of Privacy Practices

I may refuse to sign this acknowledgment. I have received and/or seen a copy of Dr. Amelia Hopper’s Notice of Privacy Practices and I understand my rights under these privacy practices.

________________________________________________________________________________________________________

Patient Name (print) Patient Signature Date

________________________________________________________________________________________________________

Office use only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

❑ Individual refused to sign

❑ Communication barriers prohibited obtaining the acknowledgement

❑ An emergency situation prevented us from obtaining acknowledgement

❑ Other :

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