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Neil L. Starr, DDS, PC

Medical History Form

Patient Information

First Name: *

Middle Name:

Last Name: *

Date: *

  

 

Residence Address: *

Residence City: *

Residence State: *

Residence Zip: *

 

Business Address: *

Business City: *

Business State: *

Business Zip: *

 

Email Address: *

Home Phone: *

Work Phone:

Cell Phone:

Employed By: *

Occupation: *

Date of Birth: *

  

Sex: *

Height: *

Weight: *

Marital Status: *

 

Contact in case of emergency: *

Relation: *

Home Number: *

Office Number: *

 

Responsible for the account
(if other than patient):

Relation:

 

Please answer the following as completely as possible:

Reason for this visit: *

Have you had any previous dental experiences worth noting:

Dentist's Name:

Referred by (we like to say 'thank you'):

Physician's Name

Physician's Phone:

Name of your Dental Insurance Company *

(Note: we are a non-participating practice and therefore do not accept any dental insurance. All payments are due as service is rendered)

 

For the following questions, answer yes or no, whichever applies.

Your answers are for our records only and will be considered confidential. Please note that during your initial visit you may be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Are you in good health? *

Yes No  

Has there been any change in your general health within the past year? *

Yes No  

Your last physical examination was on? *

Are you currently under the care of a physician? *

Yes No  

If so, what is the condition being treated?

Have you had any serious illness, operation, or been hospitalized in the past 5 years? *

Yes No  

If so, what was the illness or problem?

Are you taking any medicine(s) including non-prescription medicine? *

Yes No  

If so, what medicine(s) are you taking? (check those that apply)

 

Blood thinners:

 

Bone density medications/bisphosphonates:

 

Other:

 

Coumadin

Aredia

Tranquilizers

 

Plavix

Zometa

Sleeping pills

 

Aspirin

Fosamax

Anti depressants

 

Vitamin E

Actonel

Narcotics

 

Ginkgo Biloba

 

Herbal supplements/homeopathic remedies

 

Other:

Do you have any condition for which you require pre-medication for dental visits? *

Yes No  

Do you have any joint replacement(s), i.e. hip or knee replacement? *

Yes No  

Do you have or have you had any of the following diseases or problems?

a. Damaged heart valves, artificial heart valves, mitral valve prolapse, heart murmur or rheumatic heart disease *

Yes No  

b. Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke? *

Yes No  

a) Do you have chest pain upon exertion? *

Yes No  

b) Are you ever short of breath after mild exercise or when lying down? *

Yes No  

c) Do your ankles swell? *

Yes No  

d) Do you have inborn heart defects? *

Yes No  

e) Do you have a cardiac pacemaker? *

Yes No  

 

c. Allergy *

Yes No  

d. Sinus trouble *

Yes No  

e. Asthma or hay fever *

Yes No  

f. Fainting spells or seizures *

Yes No  

g. Persistent diarrhea or recent weight loss *

Yes No  

h. Diabetes *

Yes No  

i. Hepatitis, jaundice or liver disease *

Yes No  

j. AIDS or HIV infection *

Yes No  

k. Thyroid problems *

Yes No  

l. Respiratory problems, emphysema, bronchitis, etc. *

Yes No  

m. Arthritis or painful swollen joints *

Yes No  

n. Stomach ulcer or hyperacidity *

Yes No  

o. Kidney trouble *

Yes No  

p. Tuberculosis *

Yes No  

q. Persistent cough or cough that produces blood *

Yes No  

r. Persistent swollen glands in neck *

Yes No  

s. Low blood pressure *

Yes No  

t. Low blood sugar *

Yes No  

u. Malignant hyperthermia *

Yes No  

v. Sexually transmitted disease *

Yes No  

w. Epilepsy or other neurological disease *

Yes No  

x. Problems with mental health *

Yes No  

y. Cancer *

Yes No  

If yes, list type:

z. Problems of the immune system *

Yes No  

aa. Contagious diseases *

Yes No  

 

Do you have recurring infections of any kind? *

Yes No  

Delayed healing? (Medical or dental) *

Yes No  

Frequent or severe headaches? *

Yes No  

Numbness or tingling in any part of your body? *

Yes No  

Have you had abnormal bleeding? *

Yes No  

Have you ever required a blood transfusion? *

Yes No  

If so, when?

Do you have any blood disorder such as anemia? *

Yes No  

Bruise easily? *

Yes No  

Have you ever had any treatment for a tumor or growth? *

Yes No  

 

Are you allergic or have you had a reaction to:

a) Local anesthetics *

Yes No  

b) Penicillin *

Yes No  

c) Other antibiotics *

Yes No  

d) Sulfa drugs *

Yes No  

e) Barbiturates, tranquilizers, sedatives, or sleeping pills *

Yes No  

f) Aspirin *

Yes No  

g) Iodine *

Yes No  

h) Codeine or other narcotics *

Yes No  

i) Other medications *

Yes No  

j) Latex *

Yes No  

Do you have any disease, condition, or problem not listed above that you think I should know about? *

Yes No  

Are you wearing contact lenses? *

Yes No  

 

Women

Are you pregnant?

Yes No  

Expected due date:

Do you have any problems associated with your menstrual period?

Yes No  

Are you nursing?

Yes No  

Are you taking birth control pills?

Yes No  

 

Dental History

Do you presently have any pain, discomfort or impaired function related to your mouth? *

Yes No  

If yes, please describe:

Have you had any serious trouble associated with any previous dental treatment? *

Yes No  

If so, explain:

Do you have recurring infections of any kind? *

Yes No  

Current infection in your mouth? *

Yes No  

If yes, please describe:

Are you currently taking any antibiotics for the infection? *

Yes No  

If so, what?

Do your gums ever bleed? *

Yes No  

If so, when?

Any unhealed injuries, inflamed areas, growths, sore spots in your mouth? *

Yes No  

If so, where?

Are any of your teeth tender when you chew? *

Yes No  

Are any of your teeth more sensitive to:

Hot

Cold

Sweets

 

Certain foods/drinks

Concerned about gum recession around any of your teeth? *

Yes No  

Have you ever received Periodontal treatment? *

Yes No  

Scaling/root planning *

Yes No  

Gum surgery *

Yes No  

When did you go through Periodontal care?

Concerned about the appearance of your teeth or mouth? *

Yes No  

Pain, clicking or popping of jaws when eating or pain near ears, difficulty in opening mouth? *

Yes No  

Clench or grind your teeth? *

Yes No  

Are you wearing removable dental appliances? *

Yes No  

Interested in replacing lost teeth? *

Yes No  

Have you ever had Orthodontic treatment? *

Yes No  

With braces?

Yes No  

With removable appliances?

Yes No  

When did you go through Orthodontic treatment?

 

Additional information you feel we should know:

 

By signing below, I acknowledge that I have completed the above information to the best of my knowledge. Additionally, I will not hold my dentist or any other member of his staff responsible for any errors or omissions that I have made in the completion of this form.

Signature (Full Name) or Patient or Guardian *

 

Office Policies

I hereby authorize Dr. Neil Starr and his team to release any and all medical and dental information pertinent to my treatment to the above named insurance carrier(s) for the purposes of pre-authorization of treatment plan and fees, claims processing, utilization review or financial audit. I have been informed that this office will report my diagnosis, treatment and fees to my carrier(s) in accord with standards conforming to the current procedures established by the American Dental Association and that it is the sole responsibility of my carrier(s) to determine the actual dollar amounts of benefits for all services rendered. I understand that I am ultimately responsible for the total costs of my treatment provided by Dr. Neil Starr and his team.

Signature (Full Name) or Patient or Guardian *

 

Privacy of Information Policy

I have been informed that this practice will make reasonable efforts to protect the privacy of my health information in accord with the policies set down for dental care providers under the Health Insurance Protection and Accountability Act of 1996 and have read this practice's policy statement on privacy of patient's healthcare information. I authorize the release of any and all medical and dental information pertinent to my treatment to my other treating healthcare providers.

Signature (Full Name) or Patient or Guardian *

 

Cancellation Policy

So that we may maintain the operation of our office on sound principles and to assure you and other patients of uninterrupted treatment, it is necessary for all patients to accept and adhere to a definitive arrangement of appointments and fees. Once you have made an appointment, remember this time is reserved for you, therefore, at lease 48 hours notice must be given if cancellation is absolutely necessary, otherwise a usual fee charge of $225 will be made.

Signature (Full Name) or Patient or Guardian *

 

Payment

I understand that payment is due as service is rendered regardless of insurance coverage. (The office currently accepts payment by check, Visa, MasterCard, American Express, or Discover.)

Signature (Full Name) or Patient or Guardian *

 

Notice of Privacy Practices

(you may refuse to sign this Acknowledgement)

I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this notice. The above statements and policies and that this authorization remains valid and effective from the date of signing until revoked in writing.

Signature (Full Name) or Patient or Guardian

 

HIPAA Designation of Personal Representative

You may designate a personal representative who may act in your behalf in making decisions relating to health care, which includes treatment and payment issues. This individual can be a family member, friend, lawyer or unrelated party.

I authorize Neil L. Starr, D.D.S., P.C. to release information relating to the care and payment for:

Patient Full Name:

Street Address:

City:

State:

Zip:

Phone:

Date of Birth:

  

 

To:

Name:

Street Address:

City:

State:

Zip:

Phone:

Signature (Full Name):

 

Confirmation

 
 

Please wait, it may take a moment to submit your information.

 


Neil L. Starr, DDS, PC

Washington Office

1234 19th Street N.W. #306
Washington, DC 20036

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