Patient Dental & Medical Health History Information To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you. PATIENT INFORMATION Last Name: First Name: Middle Name: Home Phone: Cell Phone: Work Phone: Email Address: Mailing Address: City: State: Zip: Date of Birth: / / Gender: Occupation: Emergency Contact: Name: Relationship: Phone: If you are completing this form for another person, what is your name and relationship to that person? Name: __________________________________ Relationship: _______________ If executing this form as the patient’s personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing. DENTAL HISTORY & SYMPTOMS What is the reason for your visit today? Are you currently experiencing any dental pain or discomfort? n Yes n No If yes, where? When was your last dental exam? / / What was done at that appointment? When was the last time you had dental x-rays taken?to Please mark an “X” in the box ONLY if this applies you. Is it hard to open your mouth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Does it hurt to chew, bite or swallow? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Do your gums bleed when you brush or floss your teeth? . . . . . . . . . . . . . . . . . . . . . . . . . n Have you ever had periodontal (gum) treatments like scaling and root planing? . . . . . . . . n Do you have, or have you ever had, any sores or growths in your mouth? . . . . . . . . . . . n Do you clench or grind your teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Does your jaw click, pop or hurt? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Do you have earaches or neck pains? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Does dental treatment make you nervous? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Have you ever experienced any of these sleep-related breathing disorders? . . . . . . . . . n n Mouth breathing n Snoring n Trouble breathing during sleep Have you ever had a serious injury to your head or mouth? . . . . . . . . . . . . . . . . . . . . . . . . n If yes, please describe what happened and when it happened: ______________________ ____________________________________________________________________________ Have you ever had problems with dental treatment in the past? . . . . . . . . . . . . . . . . . . . . n If yes, please describe what happened: __________________________________________ ____________________________________________________________________________ Have you ever had a reaction to, or problem with, dental anesthesia? . . . . . . . . . . . . . . . n If yes, please describe what happened: __________________________________________ ____________________________________________________________________________ Are you unhappy with your smile?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n If yes, why? Please mark all that apply: n The color of your teeth n The shape of your teeth n The position of your teeth n Other. Please describe: ___________________________________________________?Is MEDICATIONS & OTHER PRODUCTS/SUBSTANCES Please use an “X” to mark your answers to the following questions. No Are you taking any blood thinners (such as Coumadin, Warfarin, rivaroxaban (Xarelto®), dabigatran (Pradaxa®), clopidogrel (Plavix®), heparin or aspirin)? . . . . . . . . . . . . . n n If yes, what medication are you taking? _________________________________________________________________________________________________________ Are you taking any medication to treat osteoporosis or Paget’s disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Yesnn n n Some commonly-prescribed drugs include alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), zolendronate (Reclast®), and denosumab (Prolia®). If yes, what medication are you taking? _________________________________________________________________________________________________________ Are you taking, or scheduled to take, an IV medication to treat bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n Some commonly-prescribed drugs include denosumab (Xgeva®), pamidronate (Aredia®) or zolendronate (Zometa®). If yes, what medication are you taking? ___________________________________________ How many years have you been taking it? ________________________ Are you taking hormonal replacements?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n Do you use any form of tobacco or nicotine products (cigarettes, cigars, snuff, chew, bidis)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n Do you use vaping products? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n How many alcoholic beverages do you have per week? __________________ Do you use controlled substances (drugs), including marijuana, for either medicinal or recreational reasons? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n If yes, what substances? ________________________________ If yes, how often is your use? n Daily n Several times per week n Weekly n Occasionally Was the substance prescribed by a doctor? n Yes n No If yes, for what reason(s)? ______________________________________________________________ Do you take any other prescriptions and/or over-the-counter medicine(s), vitamins, herbs and/or supplements? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n If yes, please list them here and include information about how much and how often you use each one. __________________________________________________ WOMEN ONLY: Are you: Taking birth control pills? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n Pregnant? If yes, number of weeks: ___________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n Nursing? If yes, number of weeks: _____________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n n n © 2021 American Dental Association Form S50021 To reorder call 800.947.4746 or go to ADAcatalog.org. Today’s Date: ___________________________________ PRE-APPOINTMENT IN-OFFICE Please use an to mark your answers to the following questions. Date:_____/_____/______ Date:_____/_____/______ 1. Do you/the patient have fever or have you/the patient felt hot or feverish recently (14–21 days)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n No n Yes n No 2. Are you/the patient having shortness of breath or other difficulties breathing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n No n Yes n No 3. Do you/the patient have a cough? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n No n Yes n No 4. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n No n Yes n No 5. Have you/the patient experienced recent loss of taste or smell? . . . . . . . . . . . . . . . n Yes n No n Yes n No 6. Are you/the patient in contact with any confirmed COVID-19 positive patients? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n No n Yes n No Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. 7. Is your/the patient’s age over 60? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n No n Yes n No 8. Do you/the patient have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n No n Yes n No 9. Have you/the patient traveled in the past 14 days? . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n No n Yes n No Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. For testing, see the Centers for Disease Control and Prevention (CDC)’s list of State and Territorial Health Department Websites for your specific area’s information: https://www.cdc.gov/publichealthgateway/healthdirectories/healthdepartments.html. Patient Name: _________________________________________________ © 2021 American Dental Association Patient Screening Form RECORD OF SERVICES PROVIDED26. 24. Procedure (MM/DD/CCYY)Date 25. of CavityOralArea Tooth System 27. Tooth Number(s) or Letter(s) 28. SurfaceTooth 29. Procedure Code 29a. PointerDiag.ofBirth 29b. Qty. 30. 31. Fee 1033.987654321 Information an on 34 Code ( ICD-10 = ) 31a. Other Fee(s) 1419 1518 34a..Diagnosisdiagnosis Diagnosis Code(s)inList“A”)Qualifier A _________________ C _________________ 321Missing31 294 28 276(Place267 258“X” 249each2310missing2112tooth.)2013 2211 1716 (Primary B _________________AB D _________________ 32. Total Fee 35. Remarks2Teeth303 AUTHORIZATIONSdentist5 ANCILLARY CLAIM/TREATMENT INFORMATION 36. I have been informed of the treatment plan and fees. I to responsible charges for dental services and materials not paid by my dental benefit plan, prohibited law, or the treating or dental practice has contractual agreement with or a portion of such charges. To the extent by law, to disclosure of my protected health information to carry payment in claim.for X _____________________________________________________________________________ Patient/Guardian Signature Dateyour 38. Place of Treatment n 11=office (Use “Place of Service Claims”) (Y or N) 40. Is Treatment for Orthodontics?(e.g.YesforProfessional No (Skip (Complete Appliance Placed (MM/DD/CCYY) 42. Months of Treatment41-42)fromCodesReplacement22=O/P41-42)Hospital) 43. of Prosthesis No Yes (Complete 44) Date of Prior Placement 37. I hereby authorize and direct payment dental benefits otherwiseDatepayable to me, directly to the below named dentist or dental entity.oftheoutpermittedaassociatedactivitiesIconsentagreeconnectionbeusemyunlesswithplanandthisprohibitingbyallall X _____________________________________________________________________________ Subscriber Signature 45. Treatment Resulting Occupational illness/injury accident Other 46. Date of Accident (MM/DD/CCYY)completed.asindicatedAutobyLOCATION44.41.39.DateEnclosures 47. Auto Accident BILLING DENTIST OR DENTAL ENTITY (Leave if dentist or dental entity is not submitting claim on behalf of the patient or insured/subscriber.)blank TREATING DENTIST AND TREATMENT INFORMATIONaccident(MM/DD/CCYY) 53. I hereby certify that the procedures date are in progress (for that multiple visits) or have been X________________________________________________________________________________requireState Signed (Treating Dentist) Dateprocedures 48. Name, Address, City, State, Zip Code 54. NPI 55. License 56. Address, City, State, Zip Code 56a. Provider Specialty CodeNumber 49. NPI 50. License 51. or TIN 52. Phone Number ( ) - 52a. Additional Provider IDSSN 57. Phone Number ( ) - 58. Additional Provider ID HEADER INFORMATIONServicesapplicable 1. Type of Transaction all boxes) Statement of Actual Request for Predetermination/Preauthorization EPSDT / Title XIX(Mark 2. Predetermination/Preauthorization Number DENTAL BENEFIT PLAN INFORMATIONCode 3. Company/Plan Name, Address, City, State, Zip OTHER COVERAGE (Mark applicable box and complete items 5-11. If blank.) 4. Dental? Medical? (If both, complete 5-11 for 5. Name of Policyholder/Subscriber in #4 (Last, First, Initial, Suffix)dentalnone, 6. Date of Birth (MM/DD/CCYY) 7. Gender M F UMiddle8.Policyholder/Subscriberonly.)IDleave by Plan) 9. Plan/Group NumberCompany/Dental 10. Patient’s Relationship to Person named in Self Spouse Dependent Other 11. Other Insurance Benefit Plan Name, Address, City, State, Zip Code#5(Assigned POLICYHOLDER/SUBSCRIBER INFORMATION (Assigned by Plan Named in #3)Zip 12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Code 13. Date of Birth (MM/DD/CCYY) 14. Gender M F U 15.Policyholder/Subscriber ID (Assigned by Plan) 16. Plan/Group Number 17. Employer Name PATIENT INFORMATION 18. Relationship to Policyholder/Subscriber in #12 Above Self Spouse Dependent Child OtherZip 19. Reserved For Future Use 20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Code 21. Date (MM/DD/CCYY) 22. Gender M F UDescription23.Patient ID/Account # (Assigned by Dentist) ©2019 American Dental AssociationJ431,Number J434 (Same as ADA Dental Claim Form J430, J432, J433, J430D) Dental Claim Form To reorder call 800.947.4746 or go online at ADAcatalog.org Child’s Dental & Medical Health History Information T o the parents/guardians of the patient: Please know that we may ask follow-up questions to make sure we have all of the information we need in PATIENT INFORMATION Last Name: First N ame: Middle Name: Nickname: Date of Birth: / / Gender: Parent’s/Guardian’s Name: Relationship to Patient: Email Address: Home Phone: Cell Phone: Work Phone: Mailing Address: City: State: Zip: Please use an “X” to mark your answers to the or the had? n A cough that’s lasted longer than three n A cough that produces blood n Please bring this form to the receptionist right away if any is the reason for your visit today? would you describe the patient’s oral health? n Excellent n Good n Fair n Poor the patient currently have any dental pain or n Yes n No If yes, where? ___________________________________________ visit a n Yes n No If no, when was the patient’s last dental ________________ What was done at that appointment? _________________________________ the had use an “X” to mark to the following Yes No ? any problem with in the past? n n n If please describe _______________________________________________________________________________ patient had any problems with teeth coming in or losin g teeth? n n n n n n are the patient’s teeth brushed? ______ time(s) per At what time(s) of day are the teeth brushed? __________ or n n n ever had a serious to the head, mouth or teeth? n n n and it ____________________________________________________________ play any contact sports or in active recreational activities? n n n Is your home water n n n primary source of drinking water? n Tap n Bottled n Filtered n Well take n n n Does/did the patient use a pacifier or suck his/her thumb or fingers? n n n At did At age the __________ the ever experienced any sleep-related breathing n Mouth breathing n Snoring n Trouble breathing during sleep © Association Form S70721 To reorder call or go to ADAcatalog.org. Today’s Date: ___________________________________“X” Dental Claim Form (2019 Version) The ADA Dental Claim Form was revised with editorial changes to form captions and check box options for gender (M, F and U) to be consistent with the HIPAA standard electronic dental claim (837D). The 2019 version is the most recent edition of the form and includes one pad of 100 8 1/2" x 11" sheets. The downloadable version of the form allows immediate access and requires no shipping not for online use. Save 20% when you order 5+ packs! J430 (shown) 8½” x 11”, 100/pad | Members $14.95 Retail $22.95 J430T Downloadable PDF | Members $19.95 Retail $29.95 J431 8.5” x 11”, Two-part carbonless, 100/pack | Members $19.95 Retail $29.95 J432 8.5” x 11”, Bond Stock, 250/pack | Members $29.95 Retail $44.95 J434 (shown) Bond in Red Ink, 100/pad | Members $14.95 Retail $22.95 NEW ADA Patient Health History Form Use the 2021 edition of the ADA Patient Dental and Medical Health History Information Form to collect pertinent health information and history from your patients before treatment. Clear, two-sided layout and simple wording make form completion easy. Includes questions related to dental history, medications and other substances, allergies, medical and surgical history and general medical symptoms. Also available as a downloadable version (S50021T) for posting on practice web sites. An additional Patient Screening Form is now included to assess patients for possible symptoms of COVID-19 in advance of their office visit. S50021 Patient Dental & Medical Health History Information Form Two pads of 100 sheets each, 8.5” x 11” Members $19.95 Retail $29.95 S50121 Spanish S70721 Child’s Dental and Medical Health History Information Form Two pads of 100 sheets each, 8.5” x 11” Members $19.95 Retail $29.95 Display your ADA pride to patients, staff and the community. NEW 2022 and 2023 Softbound ADA Appointment Books Softbound appointment book features double-column format with schedules from 7 a.m. to 5 p.m. Sturdy vinyl cover. The 2022 books are blue. Features Double-column format Schedules from 7 a.m. to 5 p.m. Lists federal holidays and other dates of interest E077 2022 Softbound, blue, 156 pages | Members $29.95 Retail $44.95 E079 2023 Softbound, black, 156 pages | Members $29.95 Retail $44.95 J430 and J434 shown 38 ORDER BY PHONE: 800.947.4746 fold fold fold
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