Child Health History Form

Child Health History Form
Patient's Name

First NameLast Name
Preferred Name
Parent or Guardian's Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birthdate

MonthDayYear
Date
Sex
Height
Weight
School
Grade Level
Whom may we thank for referring you to our office?
Preferred Office Location
Financially Responsible Party
Primary Fin. Party

First NameLast Name
Marital Status
Residence (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Previous Address (If less than 3 years.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security #
Birthdate

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
No. Years Employed
Secondary Fin. Party

First NameLast Name
Employer
Occupation
No. Years Employed
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security #
Birthdate

MonthDayYear
Date
Insurance Information
Policy Holder's Name

First NameLast Name
Policy Holder's SSN
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name
Insurance Company
Policy ID #
Policy Holder's Name

First NameLast Name
Policy Holder's SSN
Employer Name
Insurance Company
Policy ID #
Group No.
Insurance Co. Phone
Please enter a valid phone number.Format: (000) 000-0000.
Do you have dual coverage?
Policy Holder's Name

First NameLast Name
Policy Holder's SSN
Employer Name
Insurance Company
Policy ID #
Group No.
Insurance Co. Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Information
Name of nearest relative not living with you

First NameLast Name
Complete Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
Name of Family Physician
Last visit to this Dr.

MonthDayYear
Date
MD Specialist you see regularly
Speciality
Under Medical Treatment now?
If yes, for what?
Taking medication now?
If yes, for what?
List Medication:
Do you have any physical, sensory, or cognitive conditions that we should be aware of to provide you with the best care?
If yes, explain:

History Of:

Rows	Yes	No	Explanation
Heart Disease or Diabetes
Cancer or skin cancer
High Blood Pressure
Allergies or Asthma
Hepatitis
Positive HIV
Bleeding disorder or Epilepsy
Kidney or Liver Disease
Reaction to Anesthetic
Reaction to Antibiotics

Dental History
Family Dentist
Last Dental Visit

MonthDayYear
Date
How many times a day do you brush?
How many times a day do you floss?
Patient's chief concern
Dentist's chief concern
Who 1st noticed the problem?

Have you ever had:

Rows	Yes	No	Explanation
Injury to teeth
Injury to face
Stammer or Lisp
Mouth Breathing
Severe Headaches
Jaw Joint Pain
Thumb or Finger Sucking
Did parents have braces?

Previous dental treatment:

Rows	Yes	No	Explanation
Endodontic (root canal) Tx
Oral Surgery (jaw surgery) Tx
Orthodontic (braces) Tx
Periodontal (gums) Tx

Brother(s) & Sister(s) names and DOB(s):
Orthodontic problems or previous treatment:
Signature
I understand that where appropriate, credit bureau reports may be obtained.
Signature
Date

MonthDayYear

HIPAA AUTHORIZATION FORM

Authorization for Use or Disclosure of Protected Health Information
Authorization
I authorize Dr. Andrew Dietrich and Dr. Andrew Kelso to use and disclose the protected health information (PHI) described below to all treating general dentists, dental specialists, physicians, attorneys, and all insurance companies that provide benefits on behalf of
Patient Name
Effective Period:
The authorization for release of information covers all past, present and future orthodontic, general dental, and healthcare information obtained by this office.
Parent/Patient Initials.
Extent of Authorization:
I authorize the release of my complete orthodontic and dental health care records of this office, including information on the health history, and information obtained during the initial examination.
Parent/Patient Initials.
This medical and dental information may be used by our Doctors or any other person I authorize to receive this information for medical or dental consultation, billing or claims payment or other purposes I may direct.
Parent/Patient Initials.
This authorization shall be in force and effect as lang as my records are maintained by this office.
Parent/Patient Initials.
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage. I understand that the insurer has a legal right to contest a claim.
Parent/Patient Initials.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that this office will not be allowed to file claims on my behalf, without my authorization of release of this information. I understand that I may file claims on my behalf without this authorization to this office.
Parent/Patient Initials.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer protected by federal or state law.
Parent/Patient Initials.
Name of Patient/Responsible Party/ Personal Representative
Relationship to Patient
Signature of Patient/Responsible Party,/Personal Representative
MonthDayYear
Date
Should be Empty:

Child Health History Form

Financially Responsible Party

Insurance Information

Emergency Information

Medical History

Dental History

Signature

HIPAA AUTHORIZATION FORM

Authorization