MEDICAL/DENTAL HISTORY FORM FOR ADULT PATIENTS

MEDICAL/DENTAL HISTORY FORM FOR ADULT PATIENTS
Patient's First Name:*
Patient's Last Name:*
Nickname:
DOB*

MonthDayYear
Date
Gender
Age:
Patient's Street Address:*
City and State*
Zip Code*
Home #:
Cell #*
E Mail:
example@example.com
Other family members seen by us:
Who may we thank for referring you?
Your Martial Status

MarriedDivorcedSeparatedSingleRemarriedType option 6
Person Responsible for Account
First and Last Name:*
Relationship to Patient:*
DOB:*
Social Security #:
Complete Address:
Apt #:
Hm #:
Cell #:
Employer:
# of Years:
Occupation:
Emergency Contact Information
Who may we contact in the case of an emergency?
Name:*
Relationship:
Phone #:*
Primary Dental Insurance Information
Insurance Co. Name:
Member ID/Subscriber ID #:
Insurance Co. Address:
Phone #:
Do you have a Secondary Insurance Policy?

YesNo
If yes, please provide us with Secondary Insurance Information
Policy/Group #:
Insurance Co. Address
Phone #:
Name of Dentist:
Date of Last Exam:

MonthDayYear
Date
Do you require antibiotics before dental treatment? YES/NO If yes, list:
What is your primary concern?
Do you have any relatives with similar tooth or jaw relationship?

YesNo
If yes, relationship to Pt:
Have you ever been evaluated or had orthodontic treatment before?

YesNo
Do you brush your teeth daily

YesNo
Do you floss your teeth daily?

YesNo
Do you currently smoke?

YesNo
If yes, how much?
If no, have you in the past?

YesNo
If yes, how long?
Have you ever had any of the following problems?

Clenching/Grinding TeethExtra (Supernumerary) TeethFrequent Canker/Cold SoresGingivitis/PeriodontitisInjury to Face, Mouth, TeethJaw Clicking, Popping, LockingHeadachesAbnormal Bleeding/AnemiaADD/ADHDAIDS/HIV+AsthmaSinus Problems/AllergiesSleep Apnea/Use of CPAP MachineCancerCardiovascular ProblemsChest Pain/Shortness of BreathChipped or Injured Permanent or Baby TeethJaw Fractures/Cysts/AbscessMissing Permanent TeethMouth Breathing/SnoringPermanent of Extra Teeth RemovedRinging in EarsSpaced, Crooked, Protruding TeethDiabetesEndocrine/Thyroid ProblemsEpilepsy/ConvulsionsHandicaps/DisabilitiesBirth DefectsHearing ImpairmentHepatitis/Liver ProblemsArtificial Bones/JointsKidney ProblemsCongenital Heart DefectPain/tenderness in Jaw point (TMJ/TMD) or Facial MusclesSpeech ProblemsThumb/Finger SuckingTongue Thrust/Abnormal SwallowTongue/Cheek/Lip BitingTonsils and/or Adenoids RemoveRecurrent TonsillitisUnder or Over Developed JawLow Blood PressureHigh Blood PressureLupusMental Health/Behavioral ProblemsMitral Valve ProlapseOsteoporosisProsthetic Heat ValvesRheumatic FeverTuberculosisHistory of Bisphophonate medication such as: Fosamax, Actonel, Boniva, Skelid, Zometa, Didronel, Aredia, etc.
Your Physician:
Phone #:
Date of Last Physical Exam:

MonthDayYear
Date
List all medications you are currently taking:
Allergies To or Drug Reactions to:
Please discuss any serious medical conditions:
PRIVACY NOTICE & ACKNOWLEDGEMENT
1. PATIENT ACKNOWLEDGEMENT
- I hereby acknowledge that I am entitled to receive and review a copy of the office Privacy Notice.
- I understand that Drs. William Petty and Kathryn Bielik are not licensed radiologists, and are using my x-raysand/or CBCT Scan as a tool in the diagnosis and planning of orthodontic treatment.
- I understand that I may request a copy of my x-ray and/or CBCT Scan to be analyzed by a licensedradiologist or other specialist, at my own expense.
2. INSURANCE AUTHORIZATION; SIGNATURE ON FILE
- I authorize Petty & Bielik Orthodontics to keep my signature on file to be used on all insurancesubmissions, documents and/or information requested by my insurance carrier(s) relating to any and allbenefits due to me.
- I authorize the release of any information relating to my treatment to my insurance carrier(s).
- I acknowledge that I am responsible for any balance left unpaid by my insurance.
- I authorize Petty & Bielik Orthodontics to act as my agent in helping me obtain payment from myinsurance carrier(s).
- I authorize payment directly to Petty & Bielik Orthodontics.
3. E-MAIL AUTHORIZATION
- I authorize Petty & Bielik Orthodontics to transmit information relating to my treatment, health, or paymentby e-mail or other electronic means, without encryption or special security precautions, to me or someone Idesignate, or to other health care providers, health plans and administrators.
- I understand that the patient information that may be e-mailed may include my x-rays, health history,diagnosis, treatment, and payment records.
- I understand that Petty & Bielik Orthodontics does not e-mail sensitive personal information such as Social Security number, credit card number, mental health diagnosis, or genetic information.
4. PHOTO RELEASE
- I understand that Petty & Bielik Orthodontics, on occasion, may use photos/videos of the patient to be usedin the offices, on the company website, on social media, and for newsprint and related publications.
- I understand that this list is not comprehensive but serves to demonstrate situations in which the patient may be photographed or filmed.
- I authorize Petty & Bielik Orthodontics to display the patient's photo(s)/video(s) in association withcompany events, functions, publications, etc.
I hereby acknowledge that I have read & understood all four sections of this document
Signature*

Clear
INFORMED CONSENT
PATIENT NAME*
Orthodontic Treatment in the Era of COVID-19
Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also know as “Coronavirus” at any time or place. Be assured the we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continued to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.
Although exposure is unlikely, do you accept the risk and consent to treatment?*

YesNo
Covid-19 Health Screening Questionnaire
Do you, your child or anyone you have recently been in contact with have any of the following symptoms?
Fever*
Cough*
Shortness of breath or difficulty breathing*
Persistent pain, pressure, or tightness in the chest*
Recent loss of taste or smell*
Have you and/or your child recently been in contact with anyone who tested positive for or has been diagnosed as having COVID-19?*
If yes, when was the last contact with the patient?
Have you traveled outside Illinois within the last 14 days?*
If yes, where did you go and when did you return?
PATIENTS WITH A FEVER OF 100.4 DEGRESS OR HIGHER AND THOSE WITH HIGH RISK CONTACTS OR TRAVEL WILL NOT BE ADMITTED FOR APPOINTMENTS AT THIS TIME.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL/DENTAL HISTORY FORM FOR ADULT PATIENTS

Person Responsible for Account

Emergency Contact Information

Primary Dental Insurance Information

PRIVACY NOTICE & ACKNOWLEDGEMENT

INFORMED CONSENT

Orthodontic Treatment in the Era of COVID-19

Covid-19 Health Screening Questionnaire