4dorthodontics.com - Patient Medical History

Patient Medical History
Patient's Name:
Date of Birth:

MonthDayYear
Date
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry that you will be receiving. Thank you for answering the following questions.
1. Are you in good health?

YesNo
2. Have there been any changes in your general health within the past year?

YesNo
3. Date of your last physical exam:

MonthDayYear
Date
4. Physician's Name:
Address:
Phone Number:
Please enter a valid phone number.
5. Are you now under the care of a physician?

YesNo
6. Have you ever been hospitalized for any surgical operation or serious illness?

YesNo
Please Explain:
7. Are you taking any medicine(s), including non-prescription medicine?

YesNo
If yes, what medicine are you taking?
8. Have you had any abnormal bleeding?

YesNo
9. Do you bruise easily?

YesNo
10. Have you ever required a blood transfusion?

YesNo
11. Have you had a recent weight loss?

YesNo
12. Have you ever taken a Fen-Phen or Redux?

YesNo
13. Do you use tobacco?

YesNo
14. Do you use or have you used controlled substances?

YesNo
15. Are you wearing contact lenses?

YesNo
16. Do you have any disease, condition, or problem not listed above that you think I should know about
Women Only:
Are you pregnant or think you may be pregnant?

YesNo
Are you nursing?

YesNo
Are you taking birth control pills?

YesNo

Are you allergic to have you had reactions to:

	YES	NO
Local anesthetics like novocaine
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin
Iodine
Any metals (e.g., nickel, mercury, etc.)
Latex/rubber

Other (please list)

Do you have, or have you ever had, any of the following:

	YES	NO
Rheumatic heart disease or rheumatic fever
Scarlet fever
Heart defect or heart murmur
Heart trouble, heart attack, or angina
Chest pain
Shortness of breath
Pacemaker
Heart surgery
High/low blood pressure
Congenital heart problem
Swelling of feet, ankles. hands
Hepatitis, jaundice, or liver disease
Stroke
Sinus trouble
Lung or breathing problems
Asthma or hay fever
Hives or skin rash
Fainting or dizzy spells
Diabetes
AIDS or HIV infection
Thyroid problem
Allergies
Arthritis or rheumatism
Joint replacement or implant
Stomach ulcer
Kidney trouble
Tuberculosis
Persistent cough
Cough that produces blood
Chemotherapy (cancer, leukemia)
Sexually transmitted disease
Epilepsy or seizures
Anemia
Glaucoma
Nervousness
Tonsillitis
Tumors
Mental health care
Back problems
Chemical dependency
Mitral valve prolapse
Cortisone treatment
Cold sores/fever blisters
Hypoglycemia
Eating disorders

Reason for this visit
When was your last dental visit
When was done then
How often did you visit the dentist before then
Current dentist (name and location)
Have you had a complete series of dental exams (x-rays) taken? When and where
How often do you brush your teeth?
How often do you floss your teeth?
Is your drinking water fluoridated?
Do your gums bleed while brushing or flossing?

YesNo
Are your teeth sensitive to hot or cold liquids/foods?

YesNo
Are your teeth sensitive to sweet or sour liquids/foods?

YesNo
Do you feel pain to any of your teeth?

YesNo
Do you have any sores or lumps in or near your mouth?

YesNo
Have you had any head, neck, or jaw injuries?

YesNo
Have you ever experienced any of the following problems in your jaw? Clicking Pain Ooint, ear, side of face) Diffculty in opening or closing Dificulty in chewing

YesNo
Do you have frequent headaches?

YesNo
Do you clench or grind your teeth?

YesNo
Do you bite your lips or cheeks frequently?

YesNo
Do you bite your lips or cheeks frequently?

YesNo
Have you noticed any loosening of your teeth?

YesNo
Does food tend to become caught between your teeth?

YesNo
Have you ever had periodontal treatment (gums)?

YesNo
Ever worn a bite plate or other appliance?

YesNo
Have you ever had any difficult extractions in the past?

YesNo
Have you ever had any prolonged bleeding following extractions?

YesNo
Do you wear dentures or partials?

YesNo
If yes, date of placement?

MonthDayYear
Date
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

YesNo
Have you had ortho/braces in the past?

YesNo
Would you be interested in teeth whitening?

YesNo
Have you had an unfavorable dental experiences?

YesNo
If you could do anything about your smile, what would you change?
Appointments: A minimum charge will be made for failed or cancelled appointments without prior notification of 24 hours. Once an appointment is made, please remember this time has been reserved for you.

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release my information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Signature of patient or parent if minor

Clear
Date

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES

Effective April 14. 2003 (edition #1)
Fourth Dimension Orthodontics & Craniofacial Orthopedics

This notice describes how medical information about you may be used and disclosed and how you get access to this information. Please review carefully.

YOUR PRIVATE HEALTHCARE INFORMATION (PHI)

Each time you have contact with a healthcare provider for delivery of healthcare a record of your contact/visit is prepared. This record, maintained in written, oral or electronic format, contains presenting signs/symptoms, results of examination and tests, diagnoses, treatment and future care. Your medical record is the physical property of Fourth Dimension Orthodontics & Craniofacial Orthopedics ("Fourth Dimension Orthodontics"), but you have certain rights to restrict some of the use or disclosures of the information in your medical records. Fourth Dimension Orthodontics however, has the right to use and disclose the information contained in your medical record in the process of providing treatment, receiving payment and performing other regular healthcare operations such as;

Documenting and describing the care you receive for legal purposes.
Communicating with the other healthcare providers who may be involved in your care.
Educating healthcare professionals.
Medical research.
Providing information for government and public health entities responsible for improving public health and welfare.
Evaluating and improving the care you receive and the outcomes achieved.
Billing and verification of services provided to you.
Conducting other routine healthcare operations such as quality improvement studies and assessing healthcare provider competence.

Protecting your privacy and maintaining the security of your health information is one of the most important responsibilities of Fourth Dimension Orthodontics and are required by law to maintain privacy and confidentiality of your health information, provide you with this Notice of Privacy Practices, notify you of your rights to restrict use of this information, notify you if Fourth Dimension Orthodontics is unable to agree to a requested restriction, and allow you to review the Notice of Privacy Practices prior to granting consent and notifying you of changes/revisions to this notice.

EXAMPLES OF DISCLOSURE OF YOUR PRIVATE HEALTHCARE INFORMATION(PHI)

Healthcare delivery and treatment:
Information obtained from you by a physician, physician assistant, nurse or other healthcare professional is documented in your record and used for assessment, evaluation, diagnosis and treatment of medical condition(s). This information is provided to other healthcare professionals, such as physicians, specialists, physical therapists, hospital based providers and/or other healthcare providers following your treatment by Fourth Dimension Orthodontics.

Billing and Payment
Your PHI is utilized to justify the level of care delivered to you and the charges incurred for the services. This information generally accompanies the bill and is sent to our payers and other third party administrators.

Other Healthcare Operations
Fourth Dimension Orthodontics may disclose your PHI to other individuals and businesses in order for Fourth Dimension Orthodontics to perform their day to day operations. These other individuals and businesses included associates such as vendors and/or contractors used for credentialing and peer review, patient satisfaction surveys, utilization review/utilization management, billing and claims management, medical research, disease management and quality improvement initiatives, as well as management service organizations, laboratories, free standing diagnostic facilities and legal counsel. Fourth Dimension Orthodontics requires all its business associates to agree to appropriately protect the confidentiality of your PHI.

Reminders and Treatment
Fourth Dimension Orthodontics may contact you to provide you with information that we feel is useful or helpful to you based on your PHI. For example, Fourth Dimension Orthodontics may contact you (or instruct a specialist physician to whom you have been referred to contact you) to schedule an appointment or as an appointment reminder, to suggest alternative treatments, or to provide you with information (Lab results, X-Rays) on treatments you are already receiving.

Other Users and Disclosures
Fourth Dimension Orthodontics may also utilize or disclose your PHI in order to communicate with or notify family members, relatives, others responsible for your health and funeral directors. In additions, Fourth Dimension Orthodontics may disclose your PHI through other communication and reports required to be made by healthcare professionals such as public health department, law enforcement, the Food and Drug Administration, organ procurement organizations, correctional institutions and workers compensations, where applicable.

Other users and disclosures of PHI not permitted or required by law will be made only with your written authorization. You may revoke your authorization at any time provided that the revocation is in writing, except to the extent that Fourth Dimension Orthodontics has already taken action in reliance on your prior authorization.

YOUR RIGHTS CONCERNING PHI

Except as otherwise provided by law, you have the right to:
Receive a paper copy of this Notice of Privacy Practices.
Receive confidential communications of PHI if a request is submitted in writing.
Obtain a copy of PHI or records about you in a designated record set as long as the PHI is maintained in the record set.
Ask Fourth Dimension Orthodontics to amend PHI or records about you in a designated record set as long as the PHI is maintained in the record set (Fourth Dimension Orthodontics is not required to change the information if it deems it to be accurate).

Receive an accounting of disclosures of PHI (a list of the disclosures made by Fourth Dimension
Orthodontics about you for reasons other than for treatment, payment or healthcare operations); and request that Fourth Dimension Orthodontics restrict uses of disclosures of your PHI other than for treatment, payment or healthcare operations. Though Fourth Dimension Orthodontics is not required to agree to a restriction to the extent that it does not agree with your request, Fourth Dimension Orthodontics may not disclose the protected PHI in violation of the restriction unless the information is needed to provide emergency treatment, or is otherwise permitted or required by law.

Fourth Dimension Orthodontics is required by law to abide by the terms of this Notice of Privacy Practices, allow you to receive this Notice prior to grating consent, and to notify you of changes/revisions of this notice. If you believe your privacy rights have been violated, you may submit a written complaint to Fourth Dimension Orthodontics of Health and Human Services describing in detail the manner in which you feel your privacy rights have been violated. Fourth Dimension Orthodontics will not retaliate against you in any way for filling a complaint.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have been provided the Fourth Dimension Orthodontics & Craniofacial Orthopedics, ("Fourth Dimension Orthodontics"), Notice of Privacy Practices ("Notice"):
- It tells me how Fourth Dimension Orthodontics will use my health information for the purposes of my treatment, payment for my treatment and Fourth Dimension Orthodontics health care operations.
- The Notice explains in more detail how Fourth Dimension Orthodontics may use and share my health information for other reasons than treatment, payment and health care operations.
* Fourth Dimension Orthodontics will also use and share my health information as required/permitted by law.
Patients Complete Legal Name:
Patient's Date of Birth:

MonthDayYear
Date
Signature:

Clear
Date:

MonthDayYear
Date
(Patient or Legal representative*)

*May be represented to show proof of representative status
Should be Empty:

Patient Medical History

Patient Information

Responsible Party

Insurance Information

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES