Senior Smiles to Go Health History Form

Senior Smiles to Go Health History Form
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Birthday

MonthDayYear
Date
Patient Height
Patient Weight
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Social Security #
Emergency Contact Name

First NameLast Name
Relationship of Emergency Contact
Emergency Contact Phone #
Please enter a valid phone number.Format: (000) 000-0000.
What is the reason for your visit today?

Insurance Coverage
Medicaid DCN #
Insurance Member ID#
Name of Insurance Company
Group #
Name of Insured Adult
Insured Employer
Insured Adult Date of Birth

MonthDayYear
Date
Insured Social Security #
Insurance Company Phone #
Please enter a valid phone number.Format: (000) 000-0000.

We value you as our patient and need your cooperation with keeping appointments so that we can provide your care. Missing or cancelling an appointment with less than 24 hours’ notice means we are unable to fill this appointment time with another patient who desperately needs care. Our policy requires:
Timely Cancellations: If you need to cancel or reschedule your appointment, you must give us at least 24 hours’ notice. Cancellations made with less than 24 hours’ notice will be considered a missed appointment.
Initials

Clear
On Time Arrivals: If you are more than 15 minutes late to your appointment, we may need to reschedule you for another time.
Initials

Clear
Compliance: Patients are only allowed three missed appointments. After the third missed appointment, you will be placed on “same day” only status. If you have any additional appointments scheduled those appointments will be cancelled.
Initials

Clear
Many patients use Jefferson County Health Department Dental Practice’s services. Your help in keeping your appointments enables us to provide better and timelier care for all our patients.
Patient Name

First NameLast Name
Patient or Parent/Guardian Signature

Clear
DateTime

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 authorize JCHD to bill my insurance company and receive payment for dental services performed. I will not hold my dentist, or any other member of his or her staff, responsible for any action they take of do not take because of errors or omissions that I may have made in the completion of this form.
Signature

Clear
DateTime
HIPAA ACKNOWLEDGEMENT/CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
• Obtaining payment from third party payers (e.g. my insurance company);
• The day to day healthcare operations of your practice

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Type Patient Name

First NameLast Name
Signature

Clear
DateTime
Relationship to patient (if patient is unable to sign)
Should be Empty:

Rows	Yes	No	Don't know
Active Tuberculosis
Persistent cough greater that a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis

Rows	Yes	No	Don't know
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets, or pressure?
Have you had any periodontal (gum) treatments?
Have you had any problems associated with previous dental treatment?
Are you currently experiencing dental pain or discomfort?
Do you have sores or ulcers in your mouth?

Rows	Yes	No	Don't know
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa Drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever/seasonal
Animals
Food
Other

Rows	Yes	No	Don't know
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax, Actonel, Atelvia, Boniva, Reclast, Prolia) for osteoporosis or Paget's disease?
Since 2001, were you treated, or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia, Zometa, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma, or metastatic cancer?

Rows	Yes	No	Don't know
Are you currently pregnant?
Taking birth control or hormone replacement
Nursing

Rows	Yes	No	Don't know
Cardiovascular disease
Angina
Arteriosclerosis
Congestive Heart Failure
Damaged heart valves
Heart attack
Heart murmur
Hepatitis, jaundice, or liver disease
High blood pressure
Other congenital heart defects
Mitral valve prolapse
Pacemaker
Rheumatic Fever
Rheumatic Heart Disease
Abnormal Bleeding
Anemia
Rheumatoid Arthritis
Hemophilia
AIDS of HIV Infection
Arthritis
Autoimmune Disease
Neurological disorders
Systemic lupus erythematosus
Asthma
Bronchitis
Osteoporosis
Persistent swollen glands in neck
Severe Headaches/migraines
Emphysema
Sinus trouble
Tuberculosis
Cancer/Chemotherapy/Radiation
Chest pain upon exertion
Chronic pain
Diabetes Type I or II
Blood Transfusion
Malnutrition
Gastrointestinal disease
G.E. Reflux/persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Eating Disorder
Epilepsy
Fainting spells or seizures
Excessive urination
Sleep disorder
Do you snore
Mental health disorders
Severe or rapid weight loss
Kidney problems
Night sweats
Sexually transmitted disease
Recurrent infections
Low blood pressure