Microsoft word - health history2.doc

Karl E. Bohman, D.D.S., P.C. Exceptional Dentistry…One Smile at a Time
Patient Information and Health Questionnaire

Name: ___________________________________________________ Date of Birth _____________ Sex: Male Female
Name you prefer our team to address you by: _______________________ Status: Single Married Child < 18 Other: ________
Whom may we thank for referring you to our office? _________________________________________________________
Address: __________________________________________________________ Home Phone: _________________________
Number/Street City/State Zip
Business Phone: _________________________ Cell Phone: _________________________ E-mail address ____________________
Please circle preferred method of contact: Home phone Business Phone Cell phone E-mail
Employer: _____________________________________________________________
Spouse or Responsible Party to Child/Patient Name: ___________________________________________________________
Business Phone: _________________________ Employer: ______________________E-mail address ______________________
Person to contact in case of emergency: ___________________________________ Phone: ________________________________
Medical History
We are interested in your total health. Please pay close attention to our health questions so that we may be of better service to you.
Please circle any of the following, which apply to you

Heart Disease/Attack Headaches (persistent) A.I.D.S. (HIV positive) Stroke
Angina Pectoris Emphysema Hepatitis A Muscular Dystrophy
High Blood Pressure Persistent Cough Hepatitis B Multiple Sclerosis
Low Blood Pressure Tuberculosis Liver Disease Bleeding Disorders
Heart Murmur Asthma Chemical Dependency Glaucoma
Rheumatic Fever Hay Fever Hemophilia Speech Impediment
Congenital Heart Defects Sinus Trouble (Infections) Venereal Disease Anemia
Scarlet Fever Allergies or Hives Cold Sores (Fever Blisters) Arthritis (Rheumatism)
Artificial Heart Valve Diabetes Epilepsy or Seizures Hearing Problems
Pacemaker Thyroid Problems Fainting or Dizzy Spells Pregnant-Month ____
Heart Surgery Cancer or Tumors Nervous Disorders Breast feeding
Artificial Joints (Hip, Knee, etc.) Radiation Treatment Psychiatric Treatment Birth Control
Blood Transfusion (s) Chemotherapy Lupus Erythematosis
Are you aware of being allergic to or have you ever reacted adversely to any of the following?

Penicillin or other Antibiotics Codeine or other Narcotics Barbiturates or Sedatives Latex
Aspirin, Ibuprofen, Aleve Local Anesthetics (Novocaine/Xylocaine) Nitrous Oxide
Other: _________________________________________________________________________________________
Are you currently under a physician’s care: Yes No
If yes: Condition (s) being treated: ___________________________________________________________________
Physician’s Name: _____________________________________________ Phone: ____________________________
Are you currently taking any medication, drugs, or pills Yes No
If yes, please list medications and dosage? _____________________________________________________________
_______________________________________________________________________________________________
Have you been prescribed any medication you are not currently taking? Yes No
If yes, Medication and Dosage: ______________________________________________________________________
Do you have any disease, condition, or problem not listed? Yes No
If yes, please explain, _______________________________________________________________________________


Dental Insurance Information:

Insured’s Name ____________________________________Insured’s ID/SS # ______________________ Birth date _____________
Insurance Company ________________________________ Group # ___________________Relationship to Patient: ___________
Insurance Company Address ____________________________________________________________ Phone: ________________
Secondary Insured’s Name _____________________________________ Insured’s ID/SS# __________________ Birth date ______________ Insurance Company _______________________________ Group # ____________________Relationship to Patient: ______________ Insurance Company Address ____________________________________________________________ Phone: ___________________ Number/Street City/State Zip
Consent:
1. I understand the above information is necessary to provide patients with dental care in a safe and efficient manner.
2. I have answered all questions truthfully and to the best of my knowledge. I agree to notify the doctor of any changes
at subsequent visits.
3. I authorize the doctor to obtain x-rays, study models, photographs, or any other diagnostic aids deemed appropriate
to make a thorough diagnosis of the patient’s needs. I consent to be photographed before, during, and after treatment.
These photographs shall remain property of Dr. Bohman and may be published in dental journals, office manuals
and/or shown for education purposes. I understand that my first name may be used with these photos for identification
purposes.
4. I will be given the opportunity to discuss my treatment plan with the doctor prior to beginning any treatment.
5. I give my consent for the dental treatment, medication, or therapy indicated on my treatment plan and any other
treatment deemed advisable as a corollary to this treatment plan.
6. I understand that all information on this patient information form will be held in strict confidence and in accordance
with all HIPPA rules and regulations.
7. I understand this practice has a 48-hour appointment cancellation policy. In addition the practice needs to be able to
effectively contact each patient.
I understand that this practice must receive my appointment confirmation one working day in advance or my
appointment time will be offered to another patient. I understand I will receive a courtesy message to reschedule
my appointment.
If a second late notice cancellation occurs I will receive a letter to politely remind me of the 48 hour cancellation
policy.
The third late notice cancellation and beyond my account will be charged a $150.00 rescheduling fee in addition to
payment in full of the scheduled treatment should I choose to remain a patient.
Financial Responsibility:
In accordance with the Federal Truth-in-Lending Act the following policies apply in our office:
1. Payment is due at the time treatment is rendered or by previous financial arrangements.
2. In the event my insurance company does not cover the entire balance of my account within 30 days from treatment
date, I agree to pay the balance in full within 60 days of treatment date or by previous financial arrangements
3. Payments extended beyond thirty (30) days from first billing will accrue interest at the rate of 1 ½ % per month on
the unpaid balance (18% annual rate).
4. There is a forty dollar ($40) charge on all returned checks.
5. Personal credit may be checked.
6. In the event of default, I agree to pay legal interest on the indebtedness, any collection costs, and related
attorney’s fees.
Patient/Responsible Party Signature: ______________________________________________________
Date: _________________

Source: http://www.smilearizona.net/forms/Bohman_HealthHist.pdf