Patient information sheet

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Youranswers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses tothis questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This officedoes not use this information to discriminate.
If you are completing this form for another person, what is your relationship to that person? Do you have any of the following diseases or problems:
(Check DK if you Don't Know the answer to the question)
Active Tuberculosis. ■ ■ ■Persistent cough greater than a 3 week duration. ■ ■ ■Cough that produces blood . ■ ■ ■Been exposed to anyone with tuberculosis. ■ ■ ■ If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.
Dental Information For the following questions, please mark (X) your responses to the following questions. Do your gums bleed when you brush or floss? . ■ ■ ■ Do you have earaches or neck pains? . ■ ■ ■ Are your teeth sensitive to cold, hot, sweets or pressure? . ■ ■ ■ Do you have any clicking, popping or discomfort in the jaw? . ■ ■ ■ Does food or floss catch between your teeth? . ■ ■ ■ Do you brux or grind your teeth? . ■ ■ ■ Do you have sores or ulcers in your mouth? . ■ ■ ■ Have you had any periodontal (gum) treatments? . ■ ■ ■ Do you wear dentures or partials? . ■ ■ ■ Have you ever had orthodontic (braces) treatment? . ■ ■ ■ Do you participate in active recreational activities?. ■ ■ ■ Have you had any problems associated with previous dental Have you ever had a serious injury to your head or mouth?. ■ ■ ■ Is your home water supply fluoridated? . ■ ■ ■ Do you drink bottled or filtered water? . ■ ■ ■If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY Are you currently experiencing dental pain or discomfort?. ■ ■ ■ What is the reason for your dental visit today? Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. Are you now under the care of a physician? . ■ ■ ■ Have you had a serious illness, operation or been Physician Name: Phone: Include area code hospitalized in the past 5 years? . ■ ■ ■ Are you taking or have you recently taken any prescription or over the counter medicine(s)? . ■ ■ ■ Has there been any change in your general health within If so, please list all, including vitamins, natural or herbal preparations __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2007 American Dental AssociationForm S500 Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
(Check DK if you Don't Know the answer to the question)
Do you wear contact lenses? . ■ ■ ■ Do you use controlled substances (drugs)?. ■ ■ ■ Joint Replacement. Have you had an orthopedic total joint (hip,
Do you use tobacco (smoking, snuff, chew, bidis)? . ■ ■ ■ knee, elbow, finger) replacement? . ■ ■ ■ If so, how interested are you in stopping? Date: _____________ If yes, have you had any complications?_______________ (Circle one) VERY / SOMEWHAT / NOT INTERESTED Are you taking or scheduled to begin taking either of the Do you drink alcoholic beverages?. ■ ■ ■ medications, alendronate (Fosamax®) or risedronate (Actonel®) If yes, how much alcohol did you drink in the last 24 hours? ________________ for osteoporosis or Paget’s disease? . ■ ■ ■ If yes, how much do you typically drink In a week? ________________________ Since 2001, were you treated or are you presently scheduled WOMEN ONLY
WOMEN ONL
to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma Date Treatment began: _______________________________________________ Allergies - Are you allergic to or have you had a reaction to:
To all yes responses, specify type of reaction.
Metals____________________________________________________ ■ ■ ■ Local anesthetics____________________________________________ ■ ■ ■ Latex (rubber) _____________________________________________ ■ ■ ■ Aspirin ____________________________________________________ ■ ■ ■ Iodine ____________________________________________________ ■ ■ ■ Penicillin or other antibiotics __________________________________ ■ ■ ■ Hay fever/seasonal _________________________________________ ■ ■ ■ Barbiturates, sedatives, or sleeping pills ________________________ ■ ■ ■ Animals___________________________________________________ ■ ■ ■ Sulfa drugs ________________________________________________ ■ ■ ■ Food _____________________________________________________ ■ ■ ■ Codeine or other narcotics ___________________________________ ■ ■ ■ Other ____________________________________________________ ■ ■ ■ Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Artificial (prosthetic) heart valve . ■ ■ ■ Autoimmune disease . ■ ■ ■ Hepatitis, jaundice or Previous infective endocarditis . ■ ■ ■ Rheumatoid arthritis . ■ ■ ■ Damaged valves in transplanted heart . ■ ■ ■ Systemic lupus erythematosus. ■ ■ ■ Epilepsy . ■ ■ ■Congenital heart disease (CHD) Asthma. ■ ■ ■ Fainting spells or seizures. ■ ■ ■ Unrepaired, cyanotic CHD . ■ ■ ■ Bronchitis. ■ ■ ■ Neurological disorders. ■ ■ ■Repaired (completely) in last 6 months . ■ ■ ■ Emphysema . ■ ■ ■ Repaired CHD with residual defects . ■ ■ ■ Sinus trouble . ■ ■ ■ Sleep disorder . ■ ■ ■ Tuberculosis . ■ ■ ■ Mental health disorders . ■ ■ ■ Except for the conditions listed above, antibiotic prophylaxis is no longer recommended Radiation Treatment . ■ ■ ■ Recurrent Infections . ■ ■ ■ Yes No DK Chest pain upon exertion . ■ ■ ■
Cardiovascular disease. . ■ ■ ■ Mitral valve prolapse . ■ ■ ■ Chronic pain . ■ ■ ■ Kidney problems . ■ ■ ■Angina . ■ ■ ■ Pacemaker . ■ ■ ■ Diabetes Type I or II . ■ ■ ■ Night sweats. ■ ■ ■Arteriosclerosis . ■ ■ ■ Rheumatic fever . ■ ■ ■ Eating disorder. ■ ■ ■ Osteoporosis. ■ ■ ■Congestive heart failure . ■ ■ ■ Rheumatic heart disease. ■ ■ ■ Malnutrition. ■ ■ ■ Persistent swollen glands Damaged heart valves. ■ ■ ■ Abnormal bleeding . ■ ■ ■ Gastrointestinal disease. ■ ■ ■ Heart attack . ■ ■ ■ Anemia. ■ ■ ■ G.E. Reflux/persistent Heart murmur . ■ ■ ■ Blood transfusion . ■ ■ ■ If yes, date:_______________________ Ulcers . ■ ■ ■ Severe or rapid weight loss . ■ ■ ■ High blood pressure. ■ ■ ■ Hemophilia . ■ ■ ■ Thyroid problems . ■ ■ ■ Sexually transmitted disease . ■ ■ ■Other congenital heart AIDS or HIV infection . ■ ■ ■ Stroke. ■ ■ ■ Excessive urination. ■ ■ ■ defects . ■ ■ ■ Arthritis . ■ ■ ■ Glaucoma . ■ ■ ■ Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? . ■ ■ ■ Name of physician or dentist making recommendation: Do you have any disease, condition, or problem not listed above that you think I should know about? . ■ ■ ■Please explain: NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health
history and that my dentist and his/her staff will rely on this information for treating me. 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/her staff, responsible for any action they take or do not
take because of errors or omissions that I may have made in the completion of this form.
FOR COMPLETION BY DENTIST
Comments:_______________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ Waimanalo Smiles
PATIENT INFORMATION SHEET
PATIENT INFORMATION
Mark One:  Employed  FT Student  PT Student  Retired Marital Status:  Single  Married  Separated  Live-in  Widowed  Divorced Ethnicity (select one):  African American  Caucasian  Chinese  Filipino  Guamanian  Hispanic  Japanese  Korean  Native American  Native Hawaiian  Portuguese  Puerto Rican  Samoan  Vietnamese  Other Asian  Other Pacific Islander  Other Military Status:  Veteran Active Duty RESPONSIBLE PARTY INFORMATION
Mark One:  Employed  FT Student  PT Student  Retired PRIMARY DENTAL INSURANCE INFORMATION
Check One (Patient’s relationship to Insured):  Self  Spouse  Child  Step-Child  Parent  Other (Please specify) ________________________ SECONDARY DENTAL INSURANCE INFORMATION
Check One (Patient’s relationship to Insured):  Self  Spouse  Child  Step-Child  Parent  Other (Please specify) ________________________ MEDICAL INSURANCE INFORMATION
Check One (Patient’s relationship to Insured):  Self  Spouse  Child  Step-Child  Parent  Other (Please specify) ________________________ EMERGENCY CONTACT
DENTAL FINANCIAL POLICY
* I understand that I must bring my ID and insurance card to all my Dental appointments * I understand that my co-payments are due at the time of my dental appointment * I understand that my “signature on file” will be used to obtain payments from my insurance * I understand that treatment costs may change based on my CURRENT eligibility status * I understand that if I am awarded any financial grants, I give my permission to release information pertaining to my * I understand that a partial payment is expected for cases such as Partials, Dentures, Endo, and crowns. I also understand that final payments are due upon completion. * I understand that I must bring in 3 months of current income documents in order to be qualified for all discounted fees RESPONSIBLE PARTY STATEMENT
I understand that I am responsible for all charges not paid by my insurance. I also understand that future appointments may be interrupted if I fail to make timely payments. MEDICAL RELEASE AUTHORIZATION
I hereby authorize Waimanalo Smiles to release any information to my insurance carrier, organization, or Medical Doctor in I certify that the information I have furnished is true and correct to the best of my knowledge. APPOINTMENT POLICY
My Dental care is important to my health. I will try and keep all my dental appointments. If I am unable to make my appointment, I will give the office a courtesy call at least 24-48 hours notice. This will allow the staff to give my I understand that if I schedule multiple same-day appointments with my family, and I fail to make the appointment, I will not be able to schedule multiple same day appointments in the future. In addition, if I “no-show” to three (3) appointments, I will only be seen as a walk-in base for a period of 1 year. * I give my permission to the WHC dental staff to leave messages on my cell phone, home phone, E-mail or to
related members of my family, in regards to any confirmations or cancellations of any dental appointments.
Office Use Only
Consent to the Use and Disclosure of Health information for treatment, payment or
I understand as part of my dental care, this office maintains health records describing
my health history, symptoms, examination and test results, diagnoses, treatment and plans for future care. This information serves as: A communication among the health professionals who contributes to my care Information for applying my diagnosis and procedure information to my bil Means by which a 3rd party payer can verify that services bil ed were provided A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I have been provided with a NOTICE OF INFORMATION PRACTICES that provides a more complete description of information and disclosures. I have the right to review the notice prior to signing this consent. WHC (Waimanalo Health Center) reserves the right to change their notice and practices and any revisions wil be addressed. I have the right to object to the use of my health information for directory purposes. I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations. WHC is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that WHC has already taken action in reliance thereon. * I give my permission to the WHC dental staff to leave messages on my cel phone, home phone, E-mail or to related members of my family, in regards to confirming appointments, rescheduling, or cancel ing of any dental appointments. I request the fol owing restrictions to the use or disclosure of my health information: Signature of Patient or Legal Representative Witness Signature ______________________________

Source: http://waimanalohealth.org/media/W1siZiIsIjIwMTQvMDIvMDUvMTNfMDZfNTZfMTU1X0RlbnRhbF9BZHVsdF9SZWdpc3RyYXRpb25fUGFja2V0XzIwMTRfMDIucGRmIl1d/Dental%20Adult%20Registration%20Packet%202014-02.pdf?sha=9b8e61db