MEDICAL DENTAL HISTORY FORMADULT FORM

Date: ________________________

Patient’s Name: _________________________________________________________________________________________________________________

Mailing Address: _________________________________________________________________________________________________________________

Physical Address: ________________________________________________________________________________________________________________

Home Phone: ______________________ Cell Phone:_____________________ Birth Date: _________________ Social Security #: ____________________

Patient Email: _________________________________________________ Responsible Party Email: ____________________________________________

Method of appointment reminder: Email Text: (________)_________-_______________________/carrier: __________________________________

RESPONSIBLE PARTY INFORMATION

Name: ___________________________________________________________________________________ Marital Status: _________________________

Residence Address: ______________________________________________________________________________________________________________

Mailing Address: _________________________________________________________________________________________________________________

How long at this address: _______________ Home Phone: _______________________________ Work Phone: ___________________________________

Cell Phone: ____________________________________________________ Alternate Phone: __________________________________________________

Previous Address (if less than 3 years): _________________________________________________________________________________________________

Social Security #: ___________________________________ Birth Date: __________________________ Relationship to Patient: ______________________

Employer: _________________________________________________________________ No. Years Employed: ___________________________________

Occupation: _____________________________________________________________ __ Occupation No. ______________________ _________________

Spouse’s Name: ________________________________________________________________ Relationship to Patient: _____________________________

Spouse’s Employer: _________________________________________________ Occupation No. ______________________ Years Employed: __________

Spouse’s Social Security #: ___________________________________________________________ Spouse’s Birth Date: ___________________________

INSURANCE INFORMATION

Insured’s Name: _______________________________________________ DOB: ________________________ Insured’s Soc. Sec. #: _________________

Insurance Company: ______________________________________________________________________________________________________________

Group #: ________________________________________________________ Local No.: _____________________________________________________

Insurance Co. Address: ___________________________________________________________________________________________________________

Do you have dual coverage?: Yes No If Yes, please continue:

Insured’s Name: _________________________________________ Birth Date: ____________________ Insured’s Soc. Sec. #: _______________________

Insurance Company: ____________________________________________ Group #: _______________________ Local No.: ________________________

Insurance Co. Address: ___________________________________________________________________________________________________________

Insured’s Employer: ______________________________________________________________________________________________________________

EMERGENCY INFORMATION

Name of nearest relative not living with you: ___________________________________________________________________________________________

Complete Address: _______________________________________________________________________________________________________________

Phone: ____________________________________________ Relationship to Patient: _________________________________________________________

Signature: ________________________________________________________________________________ Date: ________________________________

WELCOME TO OUR OFFICEADULTS

LAST FIRST MIDDLE

STREET CITY STATE ZIP

STREET CITY STATE ZIP

LAST FIRST MIDDLE

STREET CITY STATE ZIP

STREET/P.O. BOX CITY STATE ZIP

STREET CITY STATE ZIP

LAST FIRST MIDDLE

I understand that where appropriate, credit bureau reports may be obtained. I understand and agree that I am responsible for payment. I certify this information is true and correct to the best of my knowledge.

For the following questions mark yes, no, or don’t know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

www.ohio4smiles.com

Now or in the past, have you had: yes no dk/u Birth defects or hereditary problems? yes no dk/u Bone fractures, any major accidents? yes no dk/u Rheumatoid or arthritic conditions? yes no dk/u Endocrine or thyroid problems? yes no dk/u Kidney problems? yes no dk/u Diabetes? If yes, Type I or Type II? yes no dk/u Cancer, tumor, radiation treatment or chemotherapy? yes no dk/u Stomach ulcer or hyperacidity? yes no dk/u Polio, mononucleosis, tuberculosis or pneumonia? yes no dk/u Problems of the immune system? yes no dk/u AIDS or HIV positive? yes no dk/u Hepatitis, jaundice or liver problem? yes no dk/u Fainting spells, seizures, epilepsy or neurological problem? yes no dk/u Mental health disturbance or behavioral problem? yes no dk/u Vision, hearing, tasting or speech difficulties? yes no dk/u Loss of weight recently, poor appetite? yes no dk/u History of eating disorder (anorexia, bulimia)? yes no dk/u Excessive bleeding or bruising tendency, anemia or bleeding disorder? yes no dk/u High or low blood pressure? yes no dk/u Tires easily? yes no dk/u Chest pain, shortness of breath or swelling ankles? yes no dk/u Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)? yes no dk/u Skin disorder? yes no dk/u Do you eat a well-balanced diet? yes no dk/u Frequent headaches, colds or sore throats? yes no dk/u Eye, ear, nose or throat condition? yes no dk/u Tonsil or adenoid conditions? yes no dk/u Hayfever, asthma, sinus trouble? yes no dk/u Osteoporosis?Allergies or reactions to any of the following: yes no dk/u Latex (gloves, balloons) yes no dk/u Metals (jewelry, clothing snaps) yes no dk/u Local anesthetics, such as Lidocaine yes no dk/u Acrylic yes no dk/u Medications (please specify) _______________________ yes no dk/u Foods (please specify) ____________________________ yes no dk/u Other substances (specify) _________________________ yes no dk/u Are you taking medication, nutrient supplements, herbal medications or non-prescription medicine? If yes, please name them: Medication_____________________ Taken for __________________________ Medication_____________________ Taken for __________________________ yes no dk/u Do you currently have or ever had a substance abuse problem? yes no dk/u Do you smoke or chew tobacco? yes no dk/u Operations? Describe: ____________________________ yes no dk/u Hospitalized? For: _______________________________ yes no dk/u Being treated by another health care professional? If yes, for: _________________________________________________________ yes no dk/u Other physical problems or symptoms? Describe: _________________________________________________________Are there any other medical conditions (including family medical conditions) that we should be aware of? _____________________________________________

Who may we thank for referring you to our office:_________________________________________________________________

General Dentist’s Name: ____________________________________________Now or in the past, have you had: yes no dk/u Permanent or “extra” (supernumerary) teeth removed? yes no dk/u Supernumerary (extra) or congenitally missing teeth? yes no dk/u Chipped or otherwise injured primary (baby) or permanent teeth? yes no dk/u Teeth sensitive to hot or cold; teeth throb or ache? yes no dk/u Jaw fractures, cysts or mouth infections? yes no dk/u “Dead teeth” or root canals treated? yes no dk/u Bleeding gums, bad taste or mouth odor? yes no dk/u Periodontal “gum problems”? yes no dk/u Food impaction between teeth? yes no dk/u “Gum Boils”, frequent canker sores or cold sores? yes no dk/u Thumb, finger, or sucking habit? Until what age? ________ yes no dk/u Abnormal swallowing habit (tongue thrusting)? yes no dk/u History of speech problems? yes no dk/u Mouth breathing habit, snoring or difficulty in breathing? yes no dk/u Tooth grinding, jaw clenching clicking or locking? yes no dk/u Any pain in jaw or ringing in the ears? yes no dk/u Any pain or soreness in the muscles of the face or around the ears? yes no dk/u Difficulty encountered in chewing or jaw opening? yes no dk/u Have you ever been treated for “TMD” or “TMJ” problems? yes no dk/u Aware of loose, broken or missing restorations (fillings)? yes no dk/u Any teeth irritating cheek, lip, tongue or palate? yes no dk/u Concerned about spaced, crooked or protruding teeth? yes no dk/u Aware or concerned about under or over developed jaw? yes no dk/u Any relative with similar tooth or jaw relationships? yes no dk/u Any wisdom tooth problems? yes no dk/u Had periodontal (gum) treatment? yes no dk/u Had any serious trouble associated with any previous dental treatment? yes no dk/u Been under another dentist’s care? yes no dk/u Been under another dental specialist’s care? yes no dk/u Ever had a prior orthodontic examination or treatment? yes no dk/u Would you object to wearing orthodontic appliances (braces) should they be indicated?

WOMEN ONLY yes no dk/u Are you pregnant? yes no dk/u Are you anticipating becoming pregnant?

Name: _____________________________________________

Revised May 2014

Authorization to Release Health Information

Patient Information:

Name of Patient __________________________________________ Date of Birth ___________

Address________________________________________________________________________

City, State, Zip ___________________________________________Phone _________________

At my request, Ohio Orthodontic Specialists may release the following information: (Name of the entity)

Entire record Financial records Office visit notes

Marketing* On site record review by the patient

Psychotherapy notes – if this box is checked only psychotherapy notes may be released.

Diagnostic studies (list):

Other as listed

*Financial compensation is received for this communication.

Entity or person who will receive the information:

Name _________________________________________________________________________

Address_______________________________________________________________________

City, State, Zip __________________________________________Phone _________________

Send the information electronically. Email address: _________________________________

For email communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed

inappropriately. I still elect to move forward to allow email communications to occur.

This authorization shall be in effect until the information has been forwarded as requested or

until the course of treatment is complete.

Patient Rights:

I have the right to revoke this authorization at any time.

I may inspect or copy the protected health information to be disclosed as described in this document.

Revocation is not effective in cases where the information has already been disclosed but will be effective going

forward.

Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may

no longer be protected by federal or state law.

I may refuse to sign this authorization and that my treatment will not be conditioned on signing.

I understand released information may include a communicable disease diagnosis such as HIV.

___________________________________________________Date ______________________

Signature of Patient or Personal Representative

______________________________________________________________________________

Description of Personal Representative’s Authority (attach necessary documentation)

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

Name: __________________________________________________________________________________________________

Address: _________________________________________________________________________________________________

Telephone: ________________________________________ E-mail: _________________________________________________

Patient #: _________________________________ Social Security #: _________________________________________________

SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. IF we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Contact Person: _____________________________________________________________________________

Telephone: ________________________________ Fax: ____________________________________________

E-mail: ____________________________________________________________________________________

Address: ___________________________________________________________________________________

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

SIGNATURE

I, _____________________________________________, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Signature: _______________________________ Date: __________________________________________________________

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name: ____________________________________________________________________________

Relationship to Patient: _____________________________________________________________________________________

REVOCATION OF CONSENT

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.

I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.

Signature: ___________________________________ Date: ______________________________________________________

ACKNOWLEDGEMENT OF RECEIPT NOTICE OF PRIVACY PRACTICES

OHIO ORTHODONTIC SPECIALISTS Practice Name

______________________________________________________________________

Patient Name

______________________________________________________________________

Parent Name (if applicable)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Address

______________________________________________________________________

Phone I have received a copy of the Notice of Privacy Practices for the above named practice. Patient/Parent Signature Date

For Office Use Only

We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:

An emergency existed and a signature was not possible at the time.

The individual refused to sign.

A copy was mailed with a request for signature by return mail.

Unable to communicate with the patient for the following reason:

Preparer’s Signature: __________________________________ Date: ___________