Pool Orthodontics Health History

MEDICAL AND DENTAL HISTORY FORM
PATIENT INFORMATION
Patient's Name*

First NameLast Name
Today's Date

MonthDayYear
Click or tap to change date
Date of Birth*

MonthDayYear
Click or tap to change date
Patient's Preferred Name
Sex

MaleFemale
Age
Grade (if applicable)
Marital Status

SingleMarriedDivorcedWidowed
Patient's Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address (Responsible Party)
example@example.com
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number. (*By providing a mobile number, I agree that Pool Orthodontics may send automated appointment and dental marketing messages to the number provided. I understand consent is not required for purchase.)Format: (000) 000-0000.
Cell Carrier
Choose a wireless carrier from the list above.
Preferred way to be notified of appointments (choose one)

Text MessageEmail
PARENT/GUARDIAN

(If patient is a minor)
Parent/Guardian 1

First NameLast Name
Employer/Occupation
Email Address (Responsible Party)
example@example.com
Address (if different)

Street Address

CityState
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell Carrier
Choose a wireless carrier from the list above.
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2

First NameLast Name
Employer/Occupation
Email Address (Responsible Party)
example@example.com
Address (if different)

Street Address

CityState
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell Carrier
Choose a wireless carrier from the list above.
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Patient lives with:*

Parent/Guardian 1Parent/Guardian 2BothOther
If "Other" is selected, what is the relationship/name/phone number?
FINANCIAL RESPONSIBILITY

Our office does not accept assignment or insurance benefits, and it is our financial policy that responsibility for payment lies with the patient. Reimbursement from insurance benefits will be paid directly to you.
Who is financialy responsible for the account?*

First NameLast Name
Address (if not listed above)

Street Address

Street Address Line 2

CityState

Zip Code
Employer/Occupation
Cell Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Who will be responsible for bringing patient to orthodontic treatments?
DENTAL INSURANCE

Please provide a copy of your insurance card(s) or present to front desk to be copied. Our office does not accept assignment of insurance benefits. It is our financial policy that responsibility for payment lies with patient/responsible party. We will file your insurance, and any reimbursement from insurance benefits will be paid to you directly. Failure to complete the section below ecompletely could result in delay in benefits paid to you.
Primary Policy Holder's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Click or tap to change date
Social Security Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Mailing Address (if not listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Insurance Company Name
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group #
Member ID #
Does this insurance policy have orthodontic benefits?

YesNoNot Sure
Secondary Policy Holder's Full Name

First NameLast Name
Secondary Policy Holder's Date of Birth

MonthDayYear
Click or tap to change date
Secondary Policy Holder's Social Security Number
Secondary Policy Holder's Phone Number
Please enter a valid phone numberFormat: (000) 000-0000.
Relationship to Patient
Secondary Policy Holder's Mailing Address (if not listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Policy Holder's Employer
Insurance Company Name
Secondary Policy Holder's Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group #
Member ID #
Does this insurance policy have orthodontic benefits?

YesNoNot Sure
DENTIST INFORMATION
Patient's Dentist Name
City and State

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of last visit

MonthDayYear
Click or tap to change date
Name(s) of other Dentists/Dental Professionals
PRIMARY CARE/PHYSICIAN
Patient's Physician
City and State

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of last visit

MonthDayYear
Click or tap to change date
GENERAL INFORMATION
Reason for seeking orthodontic treatment/any concerns you or your dentist might have:*
Who referred you to Dr. Pool?
Any previous orthodontic treatment?

YesNo
If so, how long?
When was the treatment?
Name/Office of Orthodontist:
Name of family members treated or seen in this office?

First NameLast Name
Does the family anticipate moving out of the area in the next 2-3 years?

YesNo
Is the patient adopted?

YesNo
PATIENT HEALTH INFORMATION
Does the patient take antibiotic pre-medication before any dental procedures?

YesNo
Is the patient allergic to any medication or substance?*

YesNo
If yes, please name the medication/substance that causes an allergic reaction:
Please list all medications, supplements, or non-prescription medicines that the patient takes:
Please list all medications, supplements, or non-prescription medicines that the patient takes as well as the dosage (if applicable):
Dental History

A thorough medical history is essential to a complete an orthodontic evaluation. All answers are confidential. For the following questions, mark yes, no, or don’t know (DK), if the patient has now or in the past.
Permanent or extra teeth (supernumerary) removed

YesNoDK
Congenitally missing teeth

YesNoDK
Chipped or injured primary or permanent teeth

YesNoDK
Any sensitive or sore teeth

YesNoDK
Jaw fractures, cyst or infections

YesNoDK
Any teeth treated with root canals or pulpotomies

YesNoDK
Frequent canker sores or cold sores

YesNoDK
History of speech problems or speech therapy

YesNoDK
Difficulty breathing through nose

YesNoDK
Mouth breathing habit or snoring at night

YesNoDK
Any gum problems, gum disease, bleeding gums

YesNoDK
Frequent habit of thumb or finger sucking

Current?YesNo
If no, age patient stopped:
Enter Days, Weeks, Months or Years
Frequent habit of fingernail biting

CurrentYesNo
If no, age patient stopped:
Enter Days, Weeks, Months or Years
Frequent habit if lip biting

CurrentYesNo
If no, age patient stopped:
Enter Days, Weeks, Months or Years
Tooth grinding or clenching

YesNoDK
Clicking or locking in jaw joint

YesNoDK
Soreness in jaw muscles or face muscles

YesNoDK
Has the patient been treated for TMJ or TMD?

YesNoDK
Tonsils or Adenoids remove

YesNoDK
Difficulty cleaning teeth

YesNoDK
Medical History

For the following questions, mark yes, no, or don’t know (DK), if the patient has now or in the past.
Emotional, sensory of developmental issues

YesNoDK
Any injuries to the face, head, neck

YesNoDK
Arthritis or joint problems

YesNoDK
Cancer, tumor, radiation or chemotherapy

YesNoDK
Endocrine or thyroid problems

YesNoDK
Diabetes or low blood sugar

YesNoDK
Kidney problems

YesNoDK
Immune system problems

YesNoDK
Herpes or any sexually transmitted diseases

YesNoDK
Emotional, sensory of developmental issues

YesNoDK
AIDS or HIV positive

YesNoDK
Hepatitis, jaundice or other liver problems

YesNoDK
Polio, mononucleosis, tuberculosis, pneumonia

YesNoDK
Seizures, fainting spells, neurologic problems

YesNoDK
Frequent headaches or migraines

YesNoDK
High or low blood pressure

YesNoDK
Excessive bleeding or bruising, anemi

YesNoDK
Chest pain, shortness of breath, tire easily

YesNoDK
Heart defect, heart murmur, heart disease

YesNoDK
Skin disorder (other than common acne)

YesNoDK
Vision, hearing or speech problems

YesNoDK
Frequent ear infection, colds, or throat infection

YesNoDK
Asthma, sinus problems, hayfever

YesNoDK
Has the patient ever had allergies or a reaction to any of the following?

Local anestheticsLatex (gloves, balloons)AspirinPenicillinAnimalsOther
If you selected "Other" above, list what caused the reaction and any details:
CONSENT FOR FAMILY MEMBERS OR OTHERS
Please list any family members or others who you give permission to obtain the information found in any orthodontic records, to include any financial arrangements. Please include yourself.
Add Family or Others Below
INFORMED CONSENT FOR THE ORTHODONTIC PATIENT

Please read carefully and then sign below.
Patient's Name*

First NameLast Name
Today's Date*

MonthDayYear
Click or tap to change date
Date of Birth*

MonthDayYear
Click or tap to change date
ACKNOWLEDGE AND CONSENT
Successful orthodontic treatment is a partnership between the orthodontist and the patient. Dr. Pool and staff are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. Occasionally before orthodontic treatment begins, there are necessary procedures that require your consent.

PLEASE READ THE FOLLOWING.

EXTRACTIONS: Some cases will require the removal of deciduous (baby) teeth. If the extraction is performed in our office, any cost will be discussed with you prior to the extraction. If the extraction is referred to your regular dentist or oral surgeon, the financial responsibility will be between you and their office.

LASER PROCEDURES: Occasionally laser treatment might be used to perform a frenectomy. A frenectomy is a surgical procedure that removes a frenulum, a small fold of tissue that contains muscle and connective tissue fibers. The frenulum can be located in several places on the body, including under the tongue, upper lip, and gums. The goal of the frenectomy is to improve range of motion or health and appearance. Additionally, laser treatment might also be used to improve the appearance of individual teeth by altering the shape and size of the gum tissue. Although very rare, damage to the oral tissue might result from laser treatment. This is generally a self-limiting short term injury that usually resolves without additional treatment. In rare circumstances, additional dental and/or medical treatment might be necessary. A topical anesthetic and/or local anesthetic will be applied to the gums before the procedure.

ORTHODONTIC STAFF: Where appropriate, office staff may be directed to perform portions of appointments as prescribed and directed by Dr. Pool.

DIAGNOSTC RECORDS: By consenting, you give permission to the making of any necessary orthodontic records, including but not limited to x-rays, before, during and following the provision of care.

ALLERGIES: It is your responsibility to notify the office staff and/or doctor of any allergies to substances or medications that may be used for treatment. Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances. This may require a change in treatment plan.
** I hereby understand and consent that I have read and fully understand the information presented on this form.*

Yes
Signature of Patient/Parent/Guardian*
Date of Signature*

MonthDayYear
Click or tap to change date
AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION

Please read carefully and then sign below.
I hereby authorize Dr. Gary Pool to provide other health care providers with information regarding the above individual’s orthodontic care as deemed appropriate. I understand that once released, Dr. Pool and staff has (have) no responsibility for any further release by the individual(s) receiving the information.
Signature of Patient/Parent/Guardian*
Date of Signature*

MonthDayYear
Click or tap to change date
CONSENT TO USE RECORDS

Please read carefully and then sign below.
I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examinations, treatment, and retention for purposes of professional consultations, research, or education.
Signature of Patient/GParent/Guardian*
Date of signature*

MonthDayYear
Date
Gary L. Pool, DMD, MS, PC

ACKNOWLEGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Please Print Full Name

First NameLast Name
Signature of person filling out form:
Form Submission Date*

MonthDayYear
Relationship to Patient:
** You may refuse to sign acknowledgment. **
Refusal to sign (check circle below if you will not be signing)

I refuse to sign
Should be Empty:

MEDICAL AND DENTAL HISTORY FORM

PATIENT INFORMATION

PARENT/GUARDIAN

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

DENTIST INFORMATION

PRIMARY CARE/PHYSICIAN

GENERAL INFORMATION

PATIENT HEALTH INFORMATION

Dental History

Medical History

CONSENT FOR FAMILY MEMBERS OR OTHERS

INFORMED CONSENT FOR THE ORTHODONTIC PATIENT

ACKNOWLEDGE AND CONSENT

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION

CONSENT TO USE RECORDS

Gary L. Pool, DMD, MS, PC

** You may refuse to sign acknowledgment. **

You may refuse to sign acknowledgment.