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

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

Yes

Your last physical examination was on? *

Are you currently under the care of a physician? *

Yes

If so, what is the condition being treated?

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

Yes

If so, what was the illness or problem?

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

Yes

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

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

Yes

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

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

Yes

a) Do you have chest pain upon exertion? *

Yes

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

Yes

c) Do your ankles swell? *

Yes

d) Do you have inborn heart defects? *

Yes

e) Do you have a cardiac pacemaker? *

Yes

c. Allergy *

Yes

d. Sinus trouble *

Yes

e. Asthma or hay fever *

Yes

f. Fainting spells or seizures *

Yes

g. Persistent diarrhea or recent weight loss *

Yes

h. Diabetes *

Yes

i. Hepatitis, jaundice or liver disease *

Yes

j. AIDS or HIV infection *

Yes

k. Thyroid problems *

Yes

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

Yes

m. Arthritis or painful swollen joints *

Yes

n. Stomach ulcer or hyperacidity *

Yes

o. Kidney trouble *

Yes

p. Tuberculosis *

Yes

q. Persistent cough or cough that produces blood *

Yes

r. Persistent swollen glands in neck *

Yes

s. Low blood pressure *

Yes

t. Low blood sugar *

Yes

u. Malignant hyperthermia *

Yes

v. Sexually transmitted disease *

Yes

w. Epilepsy or other neurological disease *

Yes

x. Problems with mental health *

Yes

y. Cancer *

Yes

If yes, list type:

z. Problems of the immune system *

Yes

aa. Contagious diseases *

Yes

Do you have recurring infections of any kind? *

Yes

Delayed healing? (Medical or dental) *

Yes

Frequent or severe headaches? *

Yes

Numbness or tingling in any part of your body? *

Yes

Have you had abnormal bleeding? *

Yes

Have you ever required a blood transfusion? *

Yes

If so, when?

Do you have any blood disorder such as anemia? *

Yes

Bruise easily? *

Yes

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

Yes

Are you allergic or have you had a reaction to:

a) Local anesthetics *

Yes

b) Penicillin *

Yes

c) Other antibiotics *

Yes

d) Sulfa drugs *

Yes

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

Yes

f) Aspirin *

Yes

g) Iodine *

Yes

h) Codeine or other narcotics *

Yes

i) Other medications *

Yes

j) Latex *

Yes

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

Yes

Are you wearing contact lenses? *

Yes

Women

Are you pregnant?

Yes

Expected due date:

Do you have any problems associated with your menstrual period?

Yes

Are you nursing?

Yes

Are you taking birth control pills?

Yes

Dental History

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

Yes

If yes, please describe:

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

Yes

If so, explain:

Do you have recurring infections of any kind? *

Yes

Current infection in your mouth? *

Yes

If yes, please describe:

Are you currently taking any antibiotics for the infection? *

Yes

If so, what?

Do your gums ever bleed? *

Yes

If so, when?

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

Yes

If so, where?

Are any of your teeth tender when you chew? *

Yes

Are any of your teeth more sensitive to:

Hot

Cold

Sweets

Certain foods/drinks

Concerned about gum recession around any of your teeth? *

Yes

Have you ever received Periodontal treatment? *

Yes

Scaling/root planning *

Yes

Gum surgery *

Yes

When did you go through Periodontal care?

Concerned about the appearance of your teeth or mouth? *

Yes

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

Yes

Clench or grind your teeth? *

Yes

Are you wearing removable dental appliances? *

Yes

Interested in replacing lost teeth? *

Yes

Have you ever had Orthodontic treatment? *

Yes

With braces?

Yes

With removable appliances?

Yes

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

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