Two Year Health History

Please take a moment to update your information as required by law every two years, thank you!

Patient Name:

Date:

SSN:

Gender:

Male Female

Family Status:

Married Single Child Other

Date of Birth:

Email:

Phone:

Address:

City:

State:

Zip:

Employer:

Emergency Contact

Name

Phone

Relationship

Expectations

We respect our patients’ time. Therefore we do everything we can do to work efficiently on treatment. We request the same from you. Please be on time and give us a 48 hour notice if you need to adjust any appointment. All broken appointments will result in a $65.00 fee.

Please Initial:

Please initial here if you do not have Dental Insurance/Self-Pay Status:

Please provide a copy of your current Dental Insurance card

HIPAA Acknowledgement

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

May we phone, email, or send a text to you to confirm appointments?

Yes No

May we leave a message on your answering machine at home or on your cell phone?

Yes No

May we discuss your medical condition with any member of your family?

Yes No

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

If YES, please name the members allowed:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient, Parent, or guardian (responsible party):

Date

Health Information

1. Are you taking prescription(s)/over-the-counter or supplement drugs? YES/NO If yes, please list medications below:

2. Do you have any allergies? YES/NO If yes, please choose all that apply: Penicillin Antibiotics Anesthetics Aspirin Foods Latex Resins

Other:

3. Do you require antibiotics before dental treatment? YES/NO If yes, what premedication (antibiotic) have you been prescribed & who is your prescriber?

4. Women: Are you pregnant? YES/NO

Yes No

Trying to get pregnant?

Yes No

Are you taking oral contraceptives?

Yes No

5. Symptoms or conditions below that you currently HAVE or HAVE HAD in the past year(s): (Please listed Year Diagnosed (DX))

Alcohol Abuse: Yes/No Year Dx:

Rheumatic Fever: Yes/No Year Dx:

Allergies to Medicine(s) : Yes/No Year Dx:

Drug Abuse: Yes/No Year Dx:

Glaucoma: Yes/No Year Dx:

Sinus problems: Yes/No Year Dx:

Osteoarthritis: Yes/No Year Dx:

Hepatitis A, B, C: Yes/No Year Dx:

Thyroid Disease: Yes/No Year Dx:

Anemia: Yes/No Year Dx:

Shingles: Yes/No Year Dx:

Asthma: Yes/No Year Dx:

Liver Problems: Yes/No Year Dx:

Kidney Disease: Yes/No Year Dx:

AIDS/HIV: Yes/No Year Dx:

Tobacco Habit: Yes/No Year Dx:

Ulcers/Colitis: Yes/No Year Dx:

STDs: Yes/No Year Dx:

Psychiatric Care: Yes/No Year Dx:

Osteoporosis: Yes/No Year Dx:

Back Problems: Yes/No Year Dx:

Stroke: Yes/No Year Dx:

Rheumatoid Arthritis: Yes/No Year Dx:

Artificial Joints: Yes/No Year Dx:

Blood Pressure (High/Low): Yes/No Year Dx:

Tuberculosis: Yes/No Year Dx:

Diabetes (I/II/III): Yes/No Year Dx:

Heart Murmur: Yes/No Year Dx:

Epilepsy: Yes/No Year Dx:

Heart Ailments/Heart Attack: Yes/No Year Dx:_

Mitral Valve Prolapse: Yes/No Year Dx:

6. Do you have any other health conditions? YES/NO If yes, please explain:

7. Are you currently taking bisphosphonate /Fosamax? Yes/No

8. Do you have history of cancer/chemotherapy/radiation? YES /NO Are you currently receiving treatment? YES/NO

9. If yes please specify:

10. Have you ever been a recipient of an organ transplant? YES/NO

11. Primary Care Physician

Phone Number

VETERAN STATUS

Are you now or have you ever served in the military?

Yes No

Patient Signature:

Date:

Your information will be encrypted.