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HEALTH HISTORY FORM
AGE________BIRTHDATE_____________S.S.NO. ________________EMAIL ADDRESS__________________ RESIDENCE ADDRESS______________________________________ HOME PHONE____________________ ______________________________________ CELL PHONE_____________________ EMPLOYED BY___________________________________________ BUS. PHONE_____________________ PRESENT POSITION________________________________________ NAME OF SPOUSE_________________________________________ SPOUSE EMPLOYER_______________ REFERRED BY____________________________________________ PERSON RESPONSIBLE FOR THIS ACCOUNT_______________________________________ DENTAL INSURANCE PLAN (IF ANY)____________________________________________________________ INSUR. CO. GROUP NO. EMPLOYER NAME INSURED’S NAME INSURED SS# IT IS IMPORTANT THAT I KNOW ABOUT YOUR DENTAL AND MEDICAL HISTORY, MANY THINGS HAVE A DIRECT BEARING ON YOUR DENTAL TREATMENT. INFORMATION YOU PROVIDE IS STRICTLY CONFIDENTIAL. YOUR MEDICAL HISTORY
PHYSICIAN’S NAME__________________________________PHONE NO.___________________________ DATE OF LAST VISIT__________________________________FOR WHAT PURPOSE?___________________ HAVE YOU EVER HAD A SERIOUS ILLNESS OR BEEN HOSPITALIZED? IF SO, EXPLAIN________________________________________________________________________ CURRENT BLOOD PRESSURE___________/___________ DO YOU PREMEDICATE WITH AN ANTIBIOTIC PRIOR TO DENTAL WORK? INDICATE WITH A CHECK MARK ANY OF THE FOLLOWING WHICH APPLY TO YOUR PAST OR PRESENT HEALTH ______ALLERGIES TO LOCAL ANESTHETICS ______OTHER ALLERGIES___________________ ______HEART CONDITION ___________________ ______BIPHOSPHONATE (FOSAMAX, ACTONEL, BONIVA) ______BLOOD THINNER (COUMADIN, ASPIRIN, PLAVIX, TICLID) ______COLD SORES ______FAINTING OR DIZZINESS ______MIGRAINE HEADACHES ______VENEREAL DISEASE ______ARTIFICIAL JOINT (HIP, KNEE, etc.) ______AIDS/HIV POSITIVE IF FEMALE, ARE YOU CURRENTLY PREGNANT? DO YOU HAVE ANY DISEASE, CONDITION, OR PROBLEMS NOT LISTED ABOVE?_____________________________ MEDICATIONS PRESENTLY BEING TAKEN:_______________________________________________________ ____________________________________________________________________________________ YOUR DENTAL HISTORY
1. WHAT IS THE REASON FOR YOUR VISIT? ______________________________________________ 2. DATE OF LAST DENTAL VISIT?_________ WHAT WAS DONE AT THAT VISIT? _____________________ 3. DATE OF LAST CLEANING? ___________ HOW OFTEN DO YOU HAVE CLEANINGS?________________
YES NO
___ ___ ARE YOU HAVING ANY DISCOMFORT AT THIS TIME? WHERE?__________________________
___ ___ DO YOU HAVE ANY SENSITIVE TEETH? (HOT, COLD, SWEETS)? WHERE?__________________
___ ___ DO YOU HAVE DISCOMFORT WHEN BITING OR CHEWING? WHERE? ______________________
___ ___ DO YOU HAVE SWELLING OR A LUMP IN YOUR MOUTH? WHERE? _______________________
___ ___ DO YOU HAVE ANY UNPLEASANT TASTES IN YOUR MOUTH?
___ ___ DO YOU HAVE ANY CONCERNS ABOUT HAVING BAD BREATH (HALITOSIS)?
___ ___ DOES FOOD WEDGE BETWEEN YOUR TEETH? WHERE? ______________________________
___ ___ ARE YOU SATISFIED WITH THE APPEARANCE OF YOUR TEETH? (COLOR, SHAPE, OVERALL SMILE)
______________________________________________________________________
___ ___ HAVE YOU EVER HAD PERIODONTAL (GUM) TREATMENT? BY WHOM? _____________________
___ ___ HAVE YOU EVER HAD ORTHODONTIC (BRACES) TREATMENT? BY WHOM? __________________
___ ___ HAVE YOU EVER HAD ENDODONTIC (ROOT CANAL) TREATMENT? BY WHOM?________________
___ ___ HAVE YOU EVER HAD ORAL SURGERY OR IMPLANTS PLACED? BY WHOM? __________________
___ ___ HAVE YOU HAD A FULL MOUTH SERIES OF X-RAYS (18) TAKEN WITHIN THE PAST YEAR?
___ ___ DO YOU HAVE PAIN IN OR NEAR YOUR EARS, POPPING, CLICKING NOISES WHEN CHEWING?
___
___ IS THERE PAIN ON OPENING WIDE OR MOVING YOUR JAW FROM LEFT TO RIGHT? ___ ___ ARE YOU AWARE IF YOU GRIND OR CLENCH YOUR TEETH? ___ ___ HAVE YOU EVER HAD AN INJURY OR TRAUMA TO YOUR FACE OR JAW? ___ ___ DO YOU SMOKE OR CHEW TOBACCO? ___ ___ DO YOU USE DENTAL FLOSS? HOW OFTEN? ___________ WHAT TYPE OF TOOTHBRUSH DO YOU USE?
NOTICE OF PRIVACY PRACTICES:
I HAVE BEEN INFORMED OF AND BEEN GIVEN THE RIGHT TO REVIEW AND SECURE A COPY OF YOUR NOTICE OF PRIVACY PRACTICES.
VISUAL IMAGES: I GIVE DR. SUPOWITZ PERMISSION FOR VISUAL IMAGES OF MY SMILE (TEETH AND LIPS ONLY, NOT FULL FACE) MADE IN CONNECTION WITH MY
DENTAL EXAMINATION AND/OR TREATMENT FOR EDUCATIONAL PURPOSES PRIMARILY IN HIS OFFICE, BUT MAY BE UTILIZED FOR EDUCATIONAL PRESENTATIONS TO DENTISTS, DENTAL STUDENTS, PATIENTS AND ON HIS COPYRIGHTED WEBSITE. THE SMILE IMAGES WILL NOT HAVE MY NAME ASSOCIATED WITH THEM.
APPOINTMENTS: ONCE AN APPOINTMENT HAS BEEN MADE, PLEASE REMEMBER THIS TIME HAS BEEN RESERVED FOR YOUR EXCLUSIVE USE. A MINIMUM CHARGE
MAY BE MADE FOR CANCELLED APPOINTMENT WITHOUT PRIOR NOTIFICATION OF AT LEAST 24 HOURS.
INSURANCE: AS A SERVICE TO YOU, OUR OFFICE WILL SUBMIT TO YOUR INSURANCE COMPANY, FEES FOR SERVICES RENDERED. THE PATIENT IS
UTLIMATELY RESPONSIBLE FOR THAT PORTION OF THE FEE WHICH IS NOT PAID BY THE INSURANCE COMPANY. I CERTIFY THAT I HAVE READ AND UNDERSTAND BOTH SIDES OF THIS FORM. 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 STAFF, RESPONSIBLE FOR ANY ERRORS OR OMISSIONS THAT I MAY HAVE MADE IN THE COMPLETION OF THIS FORM.
INSURANCE ASSIGNMENT AND RELEASE:
I AUTHORIZE DR. SUPOWITZ AND/OR ANY PROVIDERS OF SERVICES IN THIS OFFICE TO RELEASE THE INFORMATION REQUIRED TO SECURE THE PAYMENT OF BENEFITS. I AUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE SUBMISSIONS. I AUTHORIZE PAYMENT DIRECTLY TO DR. SUPOWITZ OF INSURANCE BENEFITS OTHERWISE PAYABLE TO ME FOR SERVICS RENDERED. SIGNATURE OF PATIENT __________________________________ DATE____________________ SIGNATURE OF RESPONSIBLE PARTY__________________________________ DATE____________________ MARTIN L. SUPOWITZ, DMD, MSD PITTSBURGH, PA AESTHETIC, RESTORATIVE AND IMPLANT DENTISTRY (412) 687-3232

Source: http://www.loveyoursmile.net/pdfs/Registration-Health.pdf