Health History Form - little house dentistry



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:__________

❑ High Blood pressure

❑ Heart murmur

❑ Heart valve problem

❑ Rheumatic fever

❑ Pacemaker

Bone or joint problems

❑ Arthritis

❑ Joint Replacement Date: ___________

Has a physician recommended antibiotic premedication for your dental appointments? θ yes θ no

Blood problems

❑ Easy bruising

❑ Abnormal bleeding

❑ Blood disease

❑ Blood transfusion

❑ HIV-positive/AIDS

❑

Allergy problems

❑ Hay fever / Asthma

❑ Sinus problems

❑ Skin rashes

❑ Taking allergy medication

Intestinal problems

❑ Ulcers

❑ Special diet ________________

❑ Constipation or diarrhea

Tobacco use

❑ Smoking frequency________

❑ Smokeless frequency________

❑ Past use and approximate quit date _________

Do any of the following apply?

❑ Type I or type II diabetes

❑ Family history of diabetes

❑ Stroke Date: ____________

❑ History of drug or alcohol abuse

❑ Fainting spells, seizures or epilepsy

❑ Respiratory disease (tuberculosis, COPD, other )

❑ Hepatitis, jaundice or liver trouble

❑ Thyroid problems

❑ Cancer or tumor

❑ Pregnant

❑ Nursing

Allergies

Are you allergic to, or have you reacted adversely to any of the following?

❑ Penicillin, sulfa, or other antibiotics

❑ Local anesthetics ("Novacaine")

❑ Codeine or other narcotics

❑ Barbiturates, sedatives or sleeping pills

❑ Aspirin, Acetaminophen or Ibuprofen

❑ Metals

❑ Latex

❑ Other:______________________________________

How are you feeling today? _________________________________________________

________________________________ 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? ____________________________________________

How often do you brush? ____________________________

How often do you floss? ____________________________

Do you have a dry mouth?

θ yes θ no

Are you apprehensive about dental treatment?

θ yes θ no

Have you had problems with previous dental treatment? θ yes θ no

Are you satisfied with the appearance of your teeth?

θ yes θ no

Do you avoid brushing part of your mouth due to pain? θ yes θ no

Do you gag easily?

θ yes θ no

Do you wear dentures or partials?

θ yes θ no

Do you have difficulty chewing or chew only on one side of your mouth?

θ yes θ no

Do your gums feel swollen, tender or bleed?

θ yes θ no

Have you noticed swelling, lumps or sores in your mouth?

θ yes θ no

Are your teeth sensitive to any of the following?

Hot θ yes θ no

Cold θ yes θ no

Sweets θ yes θ no

Pressure θ yes θ no

Do you have airway/sleep issues or have you been diagnosed with sleep apnea?

θ yes θ no

Do you snore?

θ yes θ no

Do you wear a night guard?

θ yes θ no

Are you aware of an uncomfortable bite?

θ yes θ no

Have you had a blow to the jaw (trauma)?

θ yes θ no

Do you have any jaw symptoms or headaches upon waking up in the morning?

θ yes θ no

Do you have pain in the face, ear, jaws, joints, throat, neck or temples?

θ yes θ no

Do you have difficulty opening your mouth?

θ yes θ no

Does your jaw make noise when eating or opening?

θ yes θ no

Do you clench or grind your teeth?

θ yes θ 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

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