New Patient - Health History

New Patient - Health History

CHAMBERS FAMILY DENTISTRY
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Date of Birth

MonthDayYear
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
An American Academy of Cosmetic Dentistry survey reveals that 92% of respondents say an attractive smile is an important asset, while 74% believe an unattractive smile can hurt a person's chances for career success. Whether your smile needs minor or more extensive improvements, your dentist can help.
Welcome to our practice! What reason(s) are you here today?
Are you currently experiencing dental pain or discomfort?

YesNo
What is the date of your last dental visit with the hygienist? (Estimate if needed)

MonthDayYear
What is the date of your last dental x-rays? (Estimate if needed)

MonthDayYear
What is the name, city, and state of your previous dentist?
Rate your smile on a scale of 1 to 10, with 10 being completely satisfied:
If you feel your smile is less than ideal, how does this affect you?

I rarely smileI smile less than I would likeI smile a lot even though my smile is less than perfectMy imperfect smile hurts my self confidenceMy imperfect smile does not bother meOther
How do you think having a wonderful smile would change your life? (Check all that apply)

I would smile more oftenI would feel better about myselfI would have more confidence with friends, family, and on the jobMy oral health would improve and be easier to maintainOther
What would you like to change about your smile? (Check all that apply)

I would like whiter, brighter teethI would like to get rid of gaps between teethI would like to repair chipped or broken teethI would like to replace missing teethI would like to change my crowded or rotated teethI would like to change my old silver fillingsI would like to improve my oral health routineOther
Have you ever had any of the following in the last 3 years? (Check all that apply)

Bad BreathBad Dental ExperienceBleeding when you brush your teethBleeding when you floss your teethBurning sensation on tongueChew on only one side of the mouthClicking, Popping, or Locking of JawDenture or Partial Denture(s)Difficult ExtractionsDry MouthEar AchesFood Collection Between TeethGrinding/Clenching TeethGums Swollen or TenderHeadachesInjury to your Head, Mouth, or TeethJaw Pain or TirednessLoose TeethMouth BreathingNeck PainOrthodontic Treatment (at any time)Periodontal Therapy (aka Deep Cleaning)Pierced TongueReaction to Dental AnestheticSensitivity to ColdSensitivity to HotSensitivity to SweetsSores or Growths in Mouth
What are some of your habits or environmental conditions that may affect your mouth? (Check all that apply)

Active Recreational Activities or JobGum ChewingHome Water Supply is Not FluoridatedIce ChewingMints or Hard CandyPen or Pencil ChewingPrimarily Drink Filtered or Bottled WaterNail BitingOther
Do you have any other comments or concerns you would like to discuss?
Emergency Contact
Name

First NameLast Name
Phone Number
Relationship to You

FriendParentSiblingSignificant OtherOther
Do you have any of the following diseases or problems? If you check any of these items, report your condition to a member of the staff immediately.

Active TuberculosisExposure to TuberuculosisPersistent cough greater than a 3 week durationCough that produces blood
Women Only (Check all that apply)

PregnantNursingBirth Control PillsHormone Replacement
How many weeks pregnant?
List the name, specialty, and phone number (if available) of all physician(s) currently caring for you:
Has there been any change in your general health in the last year?

YesNo
Please provide details here
Have you had a serious illness, operation, or been hospitalized in the past 5 years?

YesNo
Please provide details here
Has a physician or previous dentist recommended that you take antibiotics prior to dental treatment?

YesNo
List antibiotics and the physicians name, specialty, and phone number.
If you use tobacco (smoking, snuff, chew, bidis) how interested are you in stopping?

Very InterestedSomewhat InterestedNot Interested
Do you drink alcoholic beverages?

YesNo
Check all the medical conditions that apply to you:

Abnormal BleedingAIDS/HIVAllergiesAnemiaAnginaArteriosclerosisArthritisArtificial Heart ValueArtificial JointsAsthmaAutoimmune DiseaseBlood Disease/HemophiliaBlood ThinnerBlood TransfusionCancerChest Pain Upon ExertionChronic PainCodeine AllergyCongenital Heart DiseaseCongestive Heart FailureCoumadineDamaged Heart ValueDiabetesDizzinessEating DisorderEmphysemaEpilepsyExcessive BleedingExcessive UrinationFainting SpellsG.E Reflux/Persistent HeartburnGlaucomaGrowthsHay FeverHead InjuriesHearing ImpairedHeart AttackHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney ProblemsLiver DiseaseLow Blood PressureMalnutritionMental DisordersMitral Value ProlapsNervous DisordersNight SweatsOsteoporosisPacemakerPersistent Swollen Neck GlandsPrevious Infective EndocarditisRadiation TreatmentRecurrent InfectionsRespiratory ProblemsRheumatic FeverRheumatic Heart DiseaseSeizuresSevere Headaches/MigrainesSevere or Rapid Weight LossSinus ProblemsSleep DisorderSpina BifidaStomach ProblemsStrokeSystemic Lupus ErythematosusThyroid ProblemsTuberculosisTumorsUlcersVenereal DiseaseOther
Are you allergic to or have you had a reaction to: (Check all that apply)

AnimalsAspirinBarbiturateCleocinClindamycinEpinephrineErythromycinFoodIodineLatexLocal AnestheticsMetalsPenicillinSedativeSulfaTetracyclineOther
If you have had joint replacement(s), indicate joint(s), date of surgery, and any complications here:
Have you ever been or are scheduled to be treated with any of these Bisphosphonate drugs? (Check all that apply)

Alendronate (Fosamax)ArediaBonivaRisedronate (Actonel)ZometaOther
List any over the counter and prescription drugs: (Name of Medication, Dosage, Frequency)
List any disease, condition, or problem not listed above that you think we should know about. Also use this space to further explain any condition above.
I certify that I have read and understood the above and that the information given on this form is accurate. I understand the importance of a truthful dental history, and that my dentist and his/her staff will rely on this information when treating me. I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of my errors or omissions that I may have made in the completion of this form.

PATIENT HIPAA CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This provides a safeguard to my privacy.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). Theses restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:
Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc.Those records will not be available to persons other that office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient record, PHI and other documents or information.

It is the policy of this office to remind patients of their appointments. We may do this by telephone, email, text message, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. The practice utilizes a number of vendors in the conduct of business. These vendors may have access the PHI but must agree to abide by the confidentiality rules of HIPAA.

You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

Your confidential information will not be used for the purposes of marketing or
advertising of products, goods or services.

We agree to provide patients with access to their records in accordance with state and federal laws.

We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI.

FINANCIAL POLICY

Patients under the age of 18 must be accompanied by a parent. It is necessary for the parent to give permission for treatment and sign off on the medical history of the patient. The parent who accompanies the child to the office is responsible for payment.

Payment for services, including deductibles and copayments, are due at the time of the service unless other arrangements have been made prior to treatment. Payments may be made using cash, check, or credit cards.

Any arrangements for third-party financing must be made before starting treatment.

Chambers Family Dentistry accepts most dental benefit plans. We are happy to
submit the claims necessary to see that you receive your benefits. The insurance contract is an agreement between you and the insurance company. You are ultimately responsible for all charges. We cannot guarantee that any coverage estimated by your plan will be paid once a claim is filed.

In order to maximize your benefits and because plans differ from carrier to carrier, and from policy to policy, our office may refer you to your carrier or your employer’s benefits coordinator for assistance in understanding your plan.
Please note that dental insurance is intended to cover some but not all dental care costs, and not all services are covered by your plan. You are responsible for payment of all services regardless of the payable benefit.

Checks that are returned to our office from your financial institution are subject to a $35.00 returned check fee*. This fee covers the processing fees that are charged to our office.

** A $55.00 per half hour charge will be applied to your account for MISSED APPOINTMENTS OR CANCELLATIONS WITH LESS THAN 24 HOURS NOTICE**
By clicking submit, you are indicating that you have read and agree to the terms of our financial policy and HIPAA agreement.
Disclaimer: By typing your name below you, are signing this application electronically. You agree that your signature is the legal equivalent of your manual signature on this form.
First Name* Last Name* Date*
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