Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

1. About You

Patient's First Name

Middle Initial

Last Name

SSN

Birth Date

2. Dental History

Reason for Today's Visit:

Former Dentist:

Former Dentist Office:

Former Dentist Phone:

Date of Last Dental Care:

Date of Last X-Rays:

How Often do you Floss?

How Often do you Brush?

Please check if you have had problems with any of the following:

Discomfort, Clicking, or Popping in Jaw

Red, Swollen, or Bleeding Gums

Sensitive Teeth or Gums

Blisters/Sores in or Around Mouth

Lost/Broken Filling(s)

Teeth Grinding

Ringing in Ears

Broken/Chipped Tooth

Stained Teeth

Locking Jaw

Bad Breath

Your current dental health is:

Good Fair Poor

3. Medical History

Physician's Name:

Physician's Office Name:

Physician Phone:

Date of Last Visit:

Have you ever been hospitalized or had a major operation?

Yes No

If yes, please explain:

Have you ever had a serious head or neck injury?

Yes No

If yes, please explain:

Are you taking any medication, pills, or drugs?

Yes No

If yes, please explain:

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine), and Redux (dexfenfluramine).

Yes No

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?

Yes No

Are you on a special diet?

Yes No

Do you use tobacco or e-cigarettes/vape?

Yes No

Do you use controlled substances?

Yes No

If yes, please explain:

Women are you...? (Check all that apply)

Nursing?

Pregnant/Trying to get pregnant?

Taking oral contraceptives?

Are you allergic to any of the following? (Check all that apply)

Acrylic

Aspirin

Codeine

Erythromycin

Latex

Local Anesthetics

Metal

Penicillin

Sulfa Drugs

Tetracycline

Do you have, or have had, any of the following?

Alcohol / Drug Abuse

Yes No

COVID-19 / Other Infections Viruses

Yes No

HIV+ / AIDS

Yes No

Alzheimer's Disease

Yes No

Diabetes / Hypoglycemia

Yes No

Kidney Problems

Yes No

Anaphylaxis

Yes No

Difficulty Breathing

Yes No

Liver Problems

Yes No

Anxiety

Yes No

Disabilities (Learning, Speech, Other)

Yes No

Low Blood Pressure

Yes No

Artificial Joints / Valve Replacements

Yes No

Fainting / Dizziness

Yes No

Osteoporosis

Yes No

Arthritis / Rheumatism

Yes No

Frequent Headaches

Yes No

Respiratory Disease

Yes No

Asthma / Respiratory Issues

Yes No

Glaucoma

Yes No

Scarlet Fever / Rheumatic Fever

Yes No

Autism / ADD / ADHD

Yes No

Heart Attack

Yes No

Shingles

Yes No

Bleeding Abnormally / Blood Disorder

Yes No

Heart Issues / Pacemaker / Angina

Yes No

Seizures

Yes No

Cancer / Leukemia / Chemotherapy

Yes No

Heart Murmur

Yes No

Stroke

Yes No

Chemical Dependency

Yes No

Hemophilia or Abnormal Bleeding / Anemia

Yes No

Swelling of Limbs

Yes No

Circulatory Problems

Yes No

Hepatitis

Yes No

Thyroid Issues

Yes No

Cold Sores / Fever Blisters

Yes No

High Cholesterol

Yes No

Tuberculosis / Persistent or Blood Cough

Yes No

Convulsions / Epilepsy / Brain Injury

Yes No

High Blood Pressure

Yes No

Ulcers

Yes No

Venereal Diseases

Yes No

Have you ever had any serious illness not listed

Yes No

Please explain:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. Is it my responsibility to inform the dental office of any changes in medical status.

4. Notice of Privacy Practices Acknowledgement

Notice of Privacy Practices

In the course of providing service to you, we create, receive, and store health information that identifies you. I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, Plan, and Direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers (e.g. my insurance company)
Conduct normal healthcare operations such as quality assessments and physician certifications

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes:

Our submission of your health information to a billing agent or vendor for processing claims or obtaining payment
Our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment
Our submission of your health information to auditors hired by third-party payers and insurers

Other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can receive an updated copy of this notice from our office.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment, or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I acknowledge that I have read, understand, and agree to the Notice of Privacy Practice above. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations.

5. Authorization and Consent

By checking this box, I confirm this form I understand that the information I have given above is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform the office of any changes to this information. I also authorize the dental staff of Heritage Dental Studio to perform the necessary dental services I may need.

I also authorize the dental staff of Heritage Dental Studio to disclose personal health information to the following person:

Name:

Today's Date:

Your information will be encrypted.