PATIENT FORMS

Patient Information

Name:

Birth Date: Social Security #:

Home Phone: Cell Phone: Email:

Address: City: State: Zip:

Responsible Party

Name of person responsible for this account:

Relationship to patient:

Address: City: State: Zip:

Phone:

Birth Date: Drivers License #: Social Security #:

Employer: Work Phone:

Referral Information

Were you referred by one of our patients? Yes No

If yes, whom may we thank?

If no, how did you find us?

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Insurance Information

Name of insured:

Birth Date: Social Security #:

Relationship to patient:

Insurance Company Name: Policy Number:

Secondary Insurance Information

Name of insured:

Birth Date: Social Security #:

Relationship to patient:

Insurance Company Name: Policy Number:

Authorization

All of the above information is correct to the best of my knowledge. I authorize use of this form

on all my insurance submissions and I authorize the release of information to all my insurance

companies. I understand that I am responsible for my bill. I authorize HealthDent to act as my

agent in helping me to obtain payment from my insurance companies. I authorize payment to

HealthDent. I permit a copy of this authorization to be used in place of the original.

Signature: Date:

HIPAA Acknowledgement

I have read and been offered a copy* of the HealthDent Dental Notice of Privacy

Practices

*copy of HIPAA Notice of Privacy Practices attached at the end of this document

Signature: Date:

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X­Rays

Would you like us to request X­rays from a previous dental office? Yes No Doctor’s office: Phone:

Health History Your physician: Office Phone: Date of last exam: Are you under medical treatment right now? Yes No Have you ever been hospitalized for any surgical operation or serious illness? Yes No Are you taking any medications? Yes No

If yes, what medications are you taking? Please list: Have you ever been prescribed antibiotics prior to dental treatment? Yes No Are you taking or have you taken Bisphosphonate drugs? (i.e.: Fosamax, Actonel, Boniva) Yes No Have you ever taken phen­phen? Yes No Do you smoke/chew tobacco? Yes No

If yes, how much or how often?

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Are you pregnant? Yes No

If yes, when are you due? Are you allergic to or had any reactions to the following?

Local Anesthetics Yes No Penicillin or other antibiotics Yes No Codeine Yes No Latex (Rubber) Yes No Other:

Do you or have you had any of the following?

Yes No Heart Disease Yes No Rheumatic Fever Yes No Cancer Yes No Cardiac Pacemaker Yes No Asthma Yes No Arthritis Yes No Heart Murmur/MVP Yes No Emphysema Yes No Hepatitis Yes No Angina Yes No Tuberculosis Yes No High Blood Pressure Yes No Fainting/Seizures/Epilepsy Yes No Alzheimer's

Yes No Prolonged Bleeding Yes No Aids/HIV Infection Yes No Anemia Yes No Diabetes Yes No Stroke Yes No Joint Replacement/Implant Yes No Kidney Disease Yes No Sexual Transmitted Disease Yes No Thyroid Problem Yes No Cold Sores/Fever Blisters Yes No History of Substance Abuse Yes No Allergies/Sinus Issues Yes No Taking Blood Thinners

Other? Please note:

Patient Dental History Do your gums bleed while you are brushing or flossing? Yes No Are your teeth sensitive to hot or cold liquids/ foods? Yes No

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Do you have or have you had gum disease?

Yes No

Do you feel pain to any of your teeth?

Yes No

Have you ever experienced any of the following problems with your jaw?

a. Do you clench or grind your teeth?

Yes No

b. Clicking or popping?

Yes No

c. Pain (joint, ear, side of face)?

Yes No

d. Difficulty chewing?

Yes No

e. Do you have frequent headaches?

Yes No

Do you have difficulty getting numbed?

Yes No

Are you apprehensive of dental treatment?

Yes No

Have you ever had any prolonged bleeding following extraction?

Yes No

Would you be interested in whitening your teeth?

Yes No

Do you like the appearance of your teeth/smile?

Yes No

If no, please explain:

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Is there a particular issue or problem you are having that you want to discuss with the Doctor?

(i.e.: Bad Breath, Missing Teeth, Straightening Teeth)

Yes No

What would you like to discuss?

When was your last exam and cleaning done? Date:

Signature: Date:

Gum Disease

At HealthDent Dental we care not only for your teeth but for your overall health as well.

Gum disease has been linked with an increased risk for many chronic diseases. Eliminating

gum disease is especially important to the oral and overall health of the following patients.

Please take a moment to review the following and respond to those that apply to you.

Tobacco User

Tobacco users are more likely to develop gum disease which is more severe and more difficult

to eradicate. Gum disease itself has recently been linked with an increased risk for heart

disease. Since tobacco users are already at an increased risk for heart disease (and since

gum disease only worsens that risk) it is vitally important for tobacco users to do whatever is

necessary to eliminate gum disease.

Current Tobacco user

What form? (cig, pipe, chew, etc.)

How much/day?

For how long?

Previous Tobacco user

When did you quit? Date:

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Diabetes

Diabetes is a well­ known risk factor for gum disease. Research is confirming that when left

untreated gum disease makes it harder for you to control your blood sugar. Elimination of gum

disease can improve your blood sugar control reducing your risk for the serious complications.

How is your diabetes control?

Good Fair Poor

How much/day?

For how long?

Date of last A1c: What Score?

Who is your diabetes doctor?

Family History of Gum Disease

Some people are genetically prone to developing gum disease even if they decent care of

their mouths.

Do you have any family history of gum disease? Yes No

Stress

Stress is a well­ known risk factor for gum disease.

Is your stress level too high? Yes No

Life altering events (loss of jobs, divorce, death in family, moving to new location, etc.) can

be particularly strong factors for gum disease. Are you currently going through any life altering

events? Yes No

Rheumatoid Arthritis

There is a bi­directional connection between rheumatoid arthritis. If you have arthritis you are

at an increased risk for gum disease. Emerging research suggests that eliminating any gum

disease and then keeping it at bay can lessen the crippling effects of arthritis.

Have you ever been diagnosed with Rheumatoid Arthritis? Yes No

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Overweight

Being overweight is now recognized as a strong risk factor for gum disease. Obesity and gum disease are both risk factors for heart disease and diabetes. Thus, if you are over your ideal weight, it is vitally important for you to eliminate any gum inflammation to lower your risks for more serious health problems. List your current weight: List your current height: BMI = (703 x weight)/(height x height) 18.4 or below Underweight 18.5 to 24.9 Healthy Weight 25.0 to 29.9 Overweight 30.0+ Obese

Oral Cancer Screening At HealthDent Dental, we continually look for advances to ensure that we are providing the optimum level of oral healthcare to our patients. We are concerned about oral cancer and look for it in every patient. One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause of increasing incidence and mortality rates of oral cancer. As with most cancers, age is the primary risk factor for oral cancer. Tobacco and alcohol use are other major predisposing risk factors, but more than 25% of oral cancer victims have no such lifestyle risk factors. Studies also suggest that human papillomavirus (HPV 16/18) plays a role in more than 20% of oral cancer cases. Oral cancer risk by patient profile is as follows:

INCREASED RISK: Patients age 18­39, sexually active patients (HPV 16/18) HIGH RISK: Patients age 40 and older, tobacco users (ages 18­39, any type within 10

years) HIGHEST RISK: Patients age 40 and older with lifestyle risk factors (tobacco and/or

alcohol use); previous history of oral cancer For these reasons, we will always perform a cancer screening during your appointment at no extra cost to you. Signature: Date:

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