Minor Health History

Date

Patient Name

Name you wish to be called

Physical Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Mailing Address

City

State

Zip Code

Email Address

Best Time and Place to Reach You

Sex

Male Female

Birth date

Patient Social Security #

Parent name

Birth date

Social Security #

Occupation

Employer Name & Phone #

Parent name

Birth date

Social Security #

Occupation

Employer Name & Phone #

IN CASE OF EMERGENCY PLEASE CONTACT (Someone not living with you)

Name

Relationship to you

Address and Phone Number of Emergency Contact Person

Whom may we thank for referring you?

Who is responsible for this account?

Relationship to patient

Insurance Company

Group #

Subscriber’s name

Subscriber’s ID #

Subscriber’s Birth date

Relationship to Patient

Is patient covered by additional Insurance?

Yes No

Insurance Company

Group #

ASSIGNMENT AND RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with the above the insurance company and assign directly to the doctor otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. Patient portion due at the appointment. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions

Patient portion due at appointment

DIVORCE: In case of divorce or separation, the parent accompanying the child and authorizing treatment will be the parent responsible for the charges on the day of service. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

Responsible Party Signature

Relationship

Date

DENTAL HISTORY

Reason for today’s visit

Former Dentist

City/State

Date of last dental visit

Date of last dental X-rays

Bad Breath

Yes No

Blisters on lips or mouth

Yes No

Burning sensation on tongue

Yes No

Cigarette/Pipe/Cigar smoking

Yes No

Clicking/popping jaw

Yes No

Have you ever attempted to quit?

Yes No

Pain/Discomfort in jaw joint

Yes No

Chewing Tobacco

Yes Option 2

Periodontal Disease

Yes No

Have you ever attempted to quit?

Yes No

Loose teeth or broken fillings

Yes No

Have you ever attempted to quit?

Yes No

Pain around ear

Yes No

Fingernail Biting

Yes No

Sores or growths in mouth

Yes No

Grinding Teeth

Yes No

Sensitivity to Heat, Cold, Sweets or Biting.

Yes No

Lip or cheek biting

Yes No

Bleeding Gums

Yes No

Orthodontic treatment (Braces)

Yes No

Dry Mouth

Yes No

Gums Swollen

Yes No

Mouth Breathing

Yes No

Do you like your smile

Yes No

How often do you floss?

Have you ever had a serious/difficult problem associated with dental work?

Yes No

How often do you brush?

Do you drink fluorinated water or take fluoride supplements?

Yes No

Primary Care Physician’s Name

Date of last visit

Specialist’s Name

(Cardiac, Orthopedic, Oncologist, etc,.)

Date of last visit

Please check Yes or No to indicate if you have had any of the following:

AIDS/HIV Positive

Yes No

Headaches

Yes No

Kidney Disease

Yes No

Anemia

Yes No

Heart Problems:

Yes No

Liver Disease

Yes No

Arthritis, Rheumatism

Yes No

Type

Nervous Problems

Yes No

Asthma

Yes No

Congenital - Heart Lesions

Yes No

Psychiatric Care

Yes No

Back Problems

Yes No

Heart Murmur

Yes No

Respiratory Disease

Yes No

Bleeding Abnormal

Yes No

Mitral Valve - Prolapse

Yes No

Shortness Of Breath

Yes No

Tuberculosis

Yes No

Pacemaker

Yes No

Sinus Trouble

Yes No

Blood Disease

Yes Option 2

Heart Attack

Yes No

Skin Rash

Yes No

Cancer

Yes No

Date

Special Diet

Yes No

Type

High / Low Blood Pressure

Yes No

Stroke

Yes No

Chemotherapy

Yes No

Meds

Year

Radiation Treatment

Yes No

Hepatitis

Yes No

Swelling Of Feet Or Ankles

Yes No

Chemical Dependency

Yes No

Type

Thyroid Problems

Yes No

Circulatory Problems

Yes No

Oral Herpes

Yes No

Ulcer

Yes No

Cortisone Treatments

Yes No

Jaundice

Yes No

Tumor/Growth On Head Or Neck

Yes No

Cough, Persistent/bloody

Yes No

Jaw Pain

Yes No

Venereal Disease

Yes No

Diabetes (Pills, Injection or Pump)

Yes No

Joint Replacement

Yes No

Any Hosiptal Stays

Yes No

Type

Year and Type

Explain

Epilepsy

Yes No

Fainting or Dizziness

Yes No

Glaucoma

Yes No

Organ Transplant

Yes No

Organ Transplant, year and type.

Other Conditions Not Listed

Women: Are your pregnant?

Yes No

Due Date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

MEDICATIONS

Please list medications you are currently taking:

Pharmacy Name

I understand I am responsible for my account balance regardless of my insurance. I also understand that my insurance is an agreement between my insurance company and myself. WP Dental will prepare and submit necessary forms to help you obtain your benefits.

I understand that I may be charged a 1% finance charge per month (12% annually) if my balance goes beyond 60 days from date of service not from date the insurance company pays my benefits. Patient portion due at appointment.

I give permission for my dentist and clinical team to take any necessary radiographs, study models, and photographs to make a complete diagnosis of my dental needs. I also give permission for my dentist and dental team to use my photographs for in-office patient education.

I consent to the use and disclosure of my protected health information to obtain payment information in connection with my dental claims.

Responsible Party Signature

(I have read, agree to, and understand the statements listed above.)

Date

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