Health History Form
E-mail:
Today’s Date:
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your
answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to
this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office
does not use this information to discriminate.
Name:
Home Phone:
Last
First
(
Middle
Address:
Business/Cell Phone:
Include area code
)
(
City:
Include area code
)
State:
Zip:
Date of birth:
Sex:
Mailing address
Occupation:
SS# or Patient ID:
Height:
Emergency Contact:
Weight:
Relationship:
M
Home Phone:
Cell Phone:
(
(
)
F
)
Include area codes
If you are completing this form for another person, what is your relationship to that person?
Your Name
Relationship
Do you have any of the following diseases or problems:
(Check DK if you Don't Know the answer to the question)
Yes
Active Tuberculosis......................................................................................................................................................................................................... n
Persistent cough greater than a 3 week duration........................................................................................................................................................... n
Cough that produces blood ........................................................................................................................................................................................... n
Been exposed to anyone with tuberculosis..................................................................................................................................................................... n
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.
No DK
n
n
n
n
n
n
n
n
Dental Information For the following questions, please mark (X) your responses to the following questions.
Yes No DK
Do your gums bleed when you brush or floss? ...............................
Are your teeth sensitive to cold, hot, sweets or pressure? ...............
Does food or floss catch between your teeth? ................................
Is your mouth dry?..........................................................................
Have you had any periodontal (gum) treatments? ...........................
Have you ever had orthodontic (braces) treatment? ........................
Have you had any problems associated with previous dental
treatment?.......................................................................................
Is your home water supply fluoridated? ..........................................
Do you drink bottled or filtered water? ...........................................
n
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n n n
n n n
n n n
If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY
Are you currently experiencing dental pain or discomfort?.............. n n n
Yes No DK
Do you have earaches or neck pains? .............................................
Do you have any clicking, popping or discomfort in the jaw? .........
Do you brux or grind your teeth? ...................................................
Do you have sores or ulcers in your mouth? ...................................
Do you wear dentures or partials? ..................................................
Do you participate in active recreational activities?..........................
Have you ever had a serious injury to your head or mouth?............
n
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Date of your last dental exam:
What was done at that time?
Date of last dental x-rays:
What is the reason for your dental visit today?
How do you feel about your smile?
Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK
Yes No DK
Are you now under the care of a physician? ................................... n n n
Physician Name:
Phone: Include area code
(
)
Have you had a serious illness, operation or been
hospitalized in the past 5 years? ..................................................... n n n
If yes, what was the illness or problem?
Address/City/State/Zip:
Are you in good health? ................................................................. n n n
Are you taking or have you recently taken any prescription
or over the counter medicine(s)? .................................................... n n n
Has there been any change in your general health within
the past year? .................................................................................. n n n
If so, please list all, including vitamins, natural or herbal preparations
and/or diet supplements:
__________________________________________________________________
If yes, what condition is being treated?
__________________________________________________________________
__________________________________________________________________
Date of last physical exam:
© 2007 American Dental Association
Form S500
__________________________________________________________________
Medical Information
Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
(Check DK if you Don't Know the answer to the question)
Yes No DK
Do you wear contact lenses? ............................................................ n n n
Joint Replacement. Have you had an orthopedic total joint (hip,
knee, elbow, finger) replacement? ................................................... n n n
Date: _____________ If yes, have you had any complications?_______________
Are you taking or scheduled to begin taking either of the
medications, alendronate (Fosamax®) or risedronate (Actonel®)
for osteoporosis or Paget’s disease? .................................................. n n n
Since 2001, were you treated or are you presently scheduled
to begin treatment with the intravenous bisphosphonates
(Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal
complications resulting from Paget’s disease, multiple myeloma
or metastatic cancer?........................................................................ n n n
Date Treatment began: _______________________________________________
Allergies - Are you allergic to or have you had a reaction to:
Yes
To all yes responses, specify type of reaction.
Local anesthetics____________________________________________ n
Aspirin ____________________________________________________ n
Penicillin or other antibiotics __________________________________ n
Barbiturates, sedatives, or sleeping pills ________________________ n
Sulfa drugs ________________________________________________ n
Codeine or other narcotics ___________________________________ n
Yes No DK
Do you use controlled substances (drugs)?....................................... n n n
Do you use tobacco (smoking, snuff, chew, bidis)? .......................... n n n
If so, how interested are you in stopping?
(Circle one) VERY / SOMEWHAT / NOT INTERESTED
Do you drink alcoholic beverages?................................................... n n n
If yes, how much alcohol did you drink in the last 24 hours? ________________
If yes, how much do you typically drink In a week? ________________________
WOMEN ONLY Are you:
Pregnant? ........................................................................................ n nn nn
___________
Number of weeks: _____________
Taking birth control pills or hormonal replacement?......................... n nn nn
...................................................................................... n n nn nn
Nursing? ..........................................................................................
No DK
n
n
n
n
n
n
n
n
n
n
n
n
Yes No DK
Metals____________________________________________________
Latex (rubber) _____________________________________________
Iodine ____________________________________________________
Hay fever/seasonal _________________________________________
Animals___________________________________________________
Food _____________________________________________________
Other ____________________________________________________
n
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n
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n
n
n
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Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK
Artificial (prosthetic) heart valve ............................................................
Previous infective endocarditis ..............................................................
Damaged valves in transplanted heart ...................................................
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD ..............................................................
Repaired (completely) in last 6 months ............................................
Repaired CHD with residual defects ................................................
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended
for any other form of CHD.
Yes No DK
Cardiovascular disease. .........
Angina ................................
Arteriosclerosis .....................
Congestive heart failure ........
Damaged heart valves ...........
Heart attack .........................
Heart murmur ......................
Low blood pressure...............
High blood pressure ..............
Other congenital heart
defects .............................
n
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Yes No DK
n n n Autoimmune disease ............ n
n n n Rheumatoid arthritis ............. n
n n n Systemic lupus erythematosus. n
Asthma ................................ n
n n n Bronchitis ............................. n
n n n Emphysema ......................... n
n n n Sinus trouble ........................ n
Tuberculosis ......................... n
Yes No DK
Mitral valve prolapse ............. n n n
Pacemaker ........................... n n n
Rheumatic fever ................... n n n
Rheumatic heart disease ........ n n n
Abnormal bleeding ............... n n n
Anemia ................................ n n n
Blood transfusion ................. n n n
If yes, date:_______________________
Hemophilia .......................... n n n
AIDS or HIV infection ............ n n n
n Arthritis ............................... n n n
Cancer/Chemotherapy/
Radiation Treatment ...........
Chest pain upon exertion ......
Chronic pain ..........................
Diabetes Type I or II ..........
Eating disorder.......................
Malnutrition...........................
Gastrointestinal disease..........
G.E. Reflux/persistent
heartburn ...........................
Ulcers ....................................
Thyroid problems ...................
Stroke....................................
Glaucoma ..............................
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Yes No DK
Hepatitis, jaundice or
liver disease ........................ n n n
Epilepsy ................................. n n n
Fainting spells or seizures....... n n n
Neurological disorders............ n n n
If yes, specify:_____________________
Sleep disorder ........................ n n n
Mental health disorders ......... n n n
Specify:___________________________
Recurrent Infections ............... n n n
Type of infection:___________________
Kidney problems .................... n n n
Night sweats.......................... n n n
Osteoporosis.......................... n n n
Persistent swollen glands
in neck ............................... n n n
Severe headaches/
migraines ........................... n n n
Severe or rapid weight loss ..... n n n
Sexually transmitted disease .... n n n
Excessive urination ................. n n n
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? .................................................................. n n n
Phone:
Name of physician or dentist making recommendation:
Do you have any disease, condition, or problem not listed above that you think I should know about? ......................................................................... n n n
Please explain:
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health
history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth
above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not
take because of errors or omissions that I may have made in the completion of this form.
Signature of Patient/Legal Guardian:
Date:
FOR COMPLETION BY DENTIST
Comments:_______________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
East Hamilton Dental PLLC
8703 East Brainerd Rd
Chattanooga, TN 37421
423-893-7443
Notice of Privacy Practices and Patient Consent
For Use and Disclosure of Protected Health Information
_________________________________________________
PATIENT NAME
_________________
DATE
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have
certain Patient Rights regarding my protected health information.
I understand that East Hamilton Dental PLLC may use or disclose my protected health information for
treatment, payment or health care operations—which means for providing health care to me, the patient;
handling billing and payment; and, taking care of other health care operations. Unless required by law,
there will be no other uses and disclosures of this information without my authorization.
East Hamilton Dental PLLC has a detailed document called the ‘Notice of Privacy Practices’. It
contains a more complete description of your rights to privacy and how we may use and disclose
protected health information.
I understand that I have the right to read the ‘Notice’ before signing this agreement. If I ask, East
Hamilton Dental PLLC will provide me with the most current Notice of Privacy Practices.
My signature below indicates that I have been given the chance to review such copy of the Notice of
Privacy Practices. My signature means that I agree to allow East Hamilton Dental PLLC to use and
disclose my protected health information to carry out treatment, payment, and health care operations. I
have the right to revoke this consent in writing at any time, except to the extent that East Hamilton
Dental PLLC has taken action relying on this consent.
___________________________________________________
SIGNATURE (Patient or Legal Custodian/Authorized Representative)
________________
DATE
___________________________________________________
Relationship to Patient if signed by another party
________________
DATE
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our ‘Notice’ at any
time by contacting: East Hamilton Dental PLLC, 8703 East Brainerd Rd, Chattanooga, TN 37421, 423893-7443.
FORM Us
Page 1 of 1
Copyright © 2013 Stericycle, Inc. All rights reserved.
HIPAA Compliance Program
Our Office Financial Policy
Thank you for choosing us as your dental health care provider. We believe that all patients deserve the
very best dental care we can provide. We also believe that everyone benefits when specific financial
arrangements are agreed upon. Please understand that payment of your bill is considered a part of your
treatment. The following is a statement of our Financial Policy which we require the patient to read and
sign prior to any treatment. All patients must complete our information and insurance forms before
seeing the doctor.
FULL PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECKS, VISA, MASTERCARD,
DISCOVER, AMERICAN EXPRESS, AND DEBIT CARDS. WE ALSO OFFER CARE CREDIT- AN EXTENDED
PAYMENT PLAN WITH PRIOR CREDIT APPROVAL.
Regarding Insurance
We request that any co-payments, deductibles, and any services not covered by your insurance plan
be paid at the time the service is provided. The balance is your responsibility whether your insurance
company pays or not. We cannot bill your insurance unless you bring in all insurance information at
your initial visit. Your insurance policy is a contract between you and your insurance company. We are
not a party to that contract. If your insurance company has not paid your account in full within 45 days,
the balance will be automatically transferred to your account. Please be aware some and possibly all of
the services provided may be non-covered services and not considered reasonable, usual, and
customary under the terms of your dental and/or medical policy.
Usual and Customary Rates
Our practice is committed to providing the best treatment for our patients, and we charge what is usual
and customary for our area. You are responsible for payment regardless of any insurance company’s
arbitrary determination of usual and customary rates.
Adult Patients
Adult patients are responsible for full payment at the time of service. If you are unable to pay at this
time, be sure to point this out when you arrive for your appointment.
Minor Patients
The adult accompanying a minor and/or the parents (or guardians) are responsible for full payment at
the time of service. For unaccompanied minors, non-emergency treatment will be denied unless charges
have been pre-authorized to an approved credit plan, credit card, or payment by cash or check at time
Initials
Please See Back
of service has been verified. WE DO NOT BILL THIRD PARTIES. Any court order between parents is a civil
suit. The parent who brings the child is responsible for the charges.
Payment Plans
East Hamilton Dental PLLC has partnered with Care Credit, a patient financing company, to offer our
patients 0% interest financing for 6 to 12 months with approval. No other payment plans are available.
Missed Appointments
Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the
rate of a normal office visit ($30). Please understand that missed appointment times are valuable to
those patients that may find it hard to come to the dentist at other times. Please help us serve you
better by keeping your scheduled appointments. Excessive cancellations and no shows will result in
termination of our treatment agreement, and your records can be forwarded to another dental office
for a $10 fee.
Fees
All accounts that have not paid the estimated portion of their bill at the time of service will incur a $3.00
billing charge each month until the balance is paid. Balances which are 60 days old or older will incur a
monthly 1.5% finance charge which equals an 18% per annum rate. There is also a $30 returned check
fee.
Refunds
Refunds for overpayment will be sent after all treatment is completed and insurance has been collected.
Collections
Due to high cost of billing, our office prefers to have payments made at the time services are rendered.
In the event that a balance is carried with our office, the Undersigned agrees that he/she is responsible
for any and all charges incurred on this account. If the account has to be placed with a collection agency
or with an attorney, the undersigned agrees to pay any and all reasonable cost associated with the
collection and or attorney fees.
Thank you for understanding our financial policy. Please let us know if you have any questions or
concerns. We look forward to providing the highest quality dental care in a relaxing and caring
atmosphere.
I have thoroughly read the Financial Policy. I understand and agree to this Financial Policy.
Name
Signature
Date