Health History Form

Health History Form
Patient’s Name:*
Age:
Birthdate:*

MonthDayYear
Date
Gender at Birth:
Preferred Gender:
Pronouns:
Name you like to be called:
Home Phone:
Please enter a valid phone number.
School:
Grade:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hobbies/Sports/Musical Instrument:
Who may we thank for referring you to our office?
RESPONSIBLE PARTY
Name:
Marital Status:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:
example@example.com
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Parent Date of Birth:

MonthDayYear
Date
Employer:
Occupation:
DENTAL INSURANCE INFORMATION
Insured’s Name:
Insured’s ID or SS#:
Insured’s Date of Birth:

MonthDayYear
Date
Insurance Co:
Insurance Co. Address:
Group #:
Insured’s Employer:
Phone Number
Please enter a valid phone number.
Do you have dual coverage?

YesNo
Insured’s Name:
Insured’s ID or SS#:
Insured’s Date of Birth:

MonthDayYear
Date
Insurance Co:
Insurance Co. Address:
Group #:
Insured’s Employer:
Phone Number
Please enter a valid phone number.
MEDICAL/DENTAL HISTORY
Physician’s Name:
Phone:
Please enter a valid phone number.
Dentists Name:
Phone:
Please enter a valid phone number.
Are you currently under any medical treatment?

YesNo
Do you have pain, clicking, and/or popping noises in the jaw?

YesNo
Are you aware of either clenching or grinding of teeth?

YesNo
Do you have frequent headaches? How often?

YesNo
Do you have ear problems? (Aches, ringing, dizziness, fullness)

YesNo
Do you have difficulty breathing through the nose?

YesNo
Do you have habits such as nail biting, finger or thumb sucking, lip or cheek biting?

YesNo
Do you have speech problems, or are you in speech therapy?

YesNo
Have you had your tonsils and/or adenoids removed?

YesNo
Has there been any history of:

Joint swellingAsthmaTBAidsKidneyLiver ConditionEpilepsyRheumatic feverOther major illnesses?
Do you bleed easily?

YesNo
Is there a tendency to faint or become dizzy?

YesNo
Do you have allergies? (Sulphur, penicillin, novocain, etc.)

YesNo
Are you currently taking any medication? List:
Do you have a heart condition?

YesNo
Do you pre-medicate?

YesNo
Cardiologist:
Do you have sleep apnea?

YesNo
Do you smoke or chew tobacco?

YesNo
Have there been any injuries to the teeth?

YesNo
Have you had any permanent teeth extracted?

YesNo
Have we treated any other family members?

YesNo
Who:
Signature

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Date

MonthDayYear
Date
Information Release Form
Patient Name:
Date of Birth:

MonthDayYear
Date
Responsible Party Name (If patient under age 18):Responsible party name here
Messages
Please call my

HomeCellWork
If unable to reach me:

You may leave a detailed message.Please leave a message asking me to return your callPlease send me a text message reminder for my scheduled appointments.Do NOT send me text message reminders for my scheduled appointments.Other
Relationship to patient:
Signature:

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Date:

MonthDayYear
Date
Witness:

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Date:

MonthDayYear
Date
This Release of information will remain in effect until terminated by me in writing.
HIPAA
I hereby authorize Servello Orthodontics the use and disclosure of my protected health information as described below:

Your protected health information, including individually identifiable information, such as names dates, photographs, X-rays and study models may be used or disclosed for the purpose of lectures, presentations, publications, research and or Practice Marketing without disclosing or identifying individual private information.

Your protected health information such as phone/fax numbers, email addresses, home addresses, social security numbers and demographic area will not be used or disclosed for any of the above purposes but only to other health care providers (general dentist, oral surgeon, etc.); Third party payers or spouses (insurance companies, etc) in order to obtain payment of your account; Internally to all staff members who have a role in the treatment; to your family who are involved in your treatment and or to other patients and third parties who may overhear or see incidental disclosures about treatment.

This includes all past, present and future healthcare information.

Any other uses of disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke at any time.

I understand that the information used or disclosed under this authorization form may be subject to redisclosure by the person(s) or facility(ies) receiving it and would then no longer be protected by federal regulations.

I have the right to refuse to sign this authorization form. If signed, I have the right to revoke this authorization form, in writing at any time. I understand that any action already taken in reliance on this authorization cannot be reversed and my revocation will not affect those actions.
Patient name patient name here
Date

MonthDayYear
Date
Signature of Patient (Parent if minor child)

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List any person(s) you authorize disclosure of information:
Spouse

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Grandparent

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Should be Empty:

Health History Form

RESPONSIBLE PARTY

DENTAL INSURANCE INFORMATION

MEDICAL/DENTAL HISTORY

Information Release Form

Messages

HIPAA

List any person(s) you authorize disclosure of information: