Información del historial médico y dental del pacientePhone:Home
A nuestros pacientes: tenga en cuenta que podemos formular preguntas de seguimiento para asegurarnos de que tengamos toda la información que necesitamos a fin
de poder tratarlo.
INFORMACIÓN DEL PACIENTE
Apellido: Nombre: Segundo nombre:
Teléfono particular: Teléfono celular: Teléfono laboral:
Dirección de correo electrónico:
Domicilio postal: Ciudad: Estado: Código postal:
Fecha de nacimiento: //Sexo:
Ocupación:
Contacto de emergencia: Nombre: Relación: Teléfono:
Si está completando el formulario en nombre de otra persona, ¿cuál es su nombre y la relación con esa persona? Nombre: _____________________Relación: __________________
Si firma este formulario en calidad de representante personal del paciente: Declaro y garantizo que tengo pleno derecho y autoridad legal para consentir la realización de cualquier
procedimiento a este paciente. Si por alguna razón ya no tengo tal derecho y autoridad legal, lo notificaré de inmediato por escrito al consultorio.
HISTORIAL DENTAL Y SÍNTOMAS
¿Cuál es el motivo de la visita de hoy?
¿Actualmente experimenta algún dolor o malestar dental? Sí No Si es así, ¿dónde?
¿Cuándo fue el último examen dental? //¿Qué se llevó a cabo en esa cita?
¿Cuándo fue la última vez que le realizaron radiografías dentales?
Marque la casilla con una «X» SOLO si se aplica a usted.
¿Le cuesta abrir la boca? ......................................................
¿Le duele al masticar, morder o tragar? ..........................................
¿Le sangran las encías cuando se cepilla o usa hilo dental? .........................
¿Se ha sometido alguna vez a tratamientos periodontales (de encías) como
destartraje y alisado radicular? .................................................
¿Tiene, o alguna vez ha tenido, llagas o protuberancias en la boca? .................
¿Aprieta o hace rechinar los dientes? ............................................
¿Siente algún chasquido, crujido o dolor en la mandíbula? ..........................
¿Tiene dolores de oído o de cuello? .............................................
¿El tratamiento dental lo pone nervioso? ........................................
¿Alguna vez ha experimentado alguno de estos trastornos respiratorios relacionados
con el sueño? ................................................................
Respiración por boca Ronquido Dificultad para respirar durante el sueño
¿Alguna vez ha sufrido una lesión grave en la cabeza o la boca? ....................
Si es así, describa lo ocurrido y cuándo ocurrió: ___________________________________
____________________________________________________________________________
¿Ha tenido problemas con el tratamiento dental en el pasado? .....................
Si es así, describa lo ocurrido: __________________________________________________
____________________________________________________________________________
¿Alguna vez ha tenido una reacción o un problema con la anestesia dental? ..........
Si es así, describa lo ocurrido: __________________________________________________
____________________________________________________________________________
¿No le gusta su sonrisa? ......................................................
Si es así, ¿por qué? Marque donde corresponda:
El color de sus dientes La forma de sus dientes La posición de sus dientes
Otros. Describa: _________________________________________________________
MEDICACIONES Y OTROS PRODUCTOS/OTRAS SUSTANCIAS
Marque las respuestas a las siguientes preguntas con una «X». Sí No ?
¿Toma algún anticoagulante (como warfarina [Coumadin®], rivaroxabán [Xarelto®], dabigatrán [Pradaxa®], clopidogrel [Plavix®], heparina o aspirina)? .................
Si es así, ¿qué medicación toma? _______________________________________________________________________________________________________________
¿Toma alguna medicación para tratar la osteoporosis o la enfermedad de Paget? .............................................................................
Algunos medicamentos que se recetan comúnmente incluyen alendronato (Fosamax®), risedronato (Actonel®), ibandronato (Boniva®), zolendronato (Reclast®) y denosumab (Prolia®).
Si es así, ¿qué medicación toma? _______________________________________________________________________________________________________________?
¿Usa, o tiene previsto usar, medicación intravenosa (IV) para tratar el dolor de huesos, la hipercalcemia o las complicaciones óseas derivadas de la enfermedad de Paget,
el mieloma múltiple o el cáncer metastásico? ............................................................................................................
Algunos medicamentos que se recetan comúnmente incluyen denosumab (Xgeva®), pamidronato (Aredia®) o zolendronato (Zometa®).
Si es así, ¿qué medicación toma? _________________________________________________¿Hace cuántos años que la toma? _______________________________
¿Recibe terapia de sustitución hormonal?. ...............................................................................................................
¿Consume algún tipo de tabaco o productos de nicotina (cigarrillo, cigarro, rapé, tabaco para mascar, bidi)? .....................................................
¿Utiliza productos de vapeo?. ...........................................................................................................................
¿Cuántas bebidas alcohólicas consume por semana? __________________
¿Consume sustancias controladas (drogas), incluida la marihuana, por motivos medicinales o recreativos? .......................................................
Si es así, ¿qué sustancias?___________________________ Si es así, ¿con qué frecuencia? A diario Varias veces por semana Todas las semanas A veces
¿La sustancia fue recetada por un médico? Sí No Si es así, ¿por qué razones? ____________________________________________________________
¿Toma algún otro medicamento recetado o de venta libre, vitaminas, hierbas o suplementos? .............................................................
Si es así, enumérelos aquí e incluya información sobre la cantidad y la frecuencia de uso de cada uno _____________________________________________________
SOLO PARA MUJERES:
¿Toma píldoras anticonceptivas? ........................................................................................................................
¿Está embarazada? Si es así, incluya la cantidad de semanas: _____________________________.................................................................
¿Está en el periodo de lactancia? Si es así, incluya la cantidad de semanas: ________________......................................
© 2021 American Dental Association Formulario S50121 Para volver a pedirlo, llame al 800.947.4746 o visite ADAcatalog.org.
Fecha de hoy: ___________________________________Patient Dental &Medical Health History Information
To our patients: 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:
Cell Phone:
Work Phone:
Email
Mailing Address:
City:
State:
Zip:
Date of Birth: //
Gender:
Occupation:
Emergency Contact: Name:
Relationship:
Phone:
If you this form for another person, what is your name and to that person? Name:
__________________________________
Relationship: _______________
this the I I full legal and authority to to the performance of on this for reason such I the DENTAL &What is the for your visit today?we Are any dental pain or discomfort?
n Yes n No If yes, where?
last //
What was done at that appointment? last had dental Please mark an in the box if this applies to you.
Is it hard .................................................
n
Does it hurt to chew, bite or
..........................................Do
.........................nn you ever had periodontal (gum)
........n
Do you or ever any sores or growths in
...........n
clench grind your
...................................
n .................................
n .........................................Does dental treatment make you
......................................nn
.........n
n Snoring n breathing during sleep
Have you ever had a serious injury to your head or mouth?
........................If
______________________n ____________________________________________________________________________Have you ever had problems with dental treatment in the
n
If ____________________________________________________________________________....................dentalwith,__________________________________________problemorto,reactionahadeveryou Have If
__________________________________________..............____________________________________________________________________________.n Are you unhappy with your smile?.
.............................................n If why? all apply:
n The color of your teeth
n The shape of your teeth
n The position of your teeth
n Other. Please describe: ___________________________________________________
&PRODUCTS/SUBSTANCES the
Yes No ?
Are you taking any blood thinners Warfarin, rivaroxaban (Xarelto®), dabigatran or
.............n n n
_________________________________________________________________________________________________________to
osteoporosis or Paget’s disease? ..........................................................
n n n
If yes, what medication are you taking? Are or an
IV to treat bone pain, hypercalcemia
or metastatic ................................
n n n
If ___________________________________________
How many years have you been taking it?
________________________
Are taking replacements.? .........................................................
n n n
or products
......................................................
n n n
Do use .............................
n n n
How many
__________________
you or
............................................
n n n
________________________________
If yes, how often is your use?
n Daily n
n Weekly n Occasionally
n Yes n No If ______________________________________________________________prescriptions over-the-counter
................................
n n n
use
__________________________________________________..
Taking birth control pills? .....................................................................................
n n n
___________________................................................................................................
n n n
?If
_____________________..................................................................................................
n n n
800.947.4746 go ADAcatalog.org.
Today’s Date: ___________________________________
Child’s Dental &Medical Health History Information
To the parents/guardians of the patient: Please know that we may ask all of the information we need in
the patient.
PATIENT INFORMATION
Last Name: First Name: 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 following question.
Have you (the adult) or the patient (the child) had? n A cough that’s lasted longer than three weeks n A cough that produces blood
n Active Tuberculosis
to the receptionist right away if you marked “Yes” any these items.
PATIENT’S DENTAL HEALTH HISTORY
What is the reason for your visit today?
How would you describe the patient’s oral health? n Excellent n Good n Fair n Poor
Does the patient currently have any dental pain or discomfort? n Yes n No If yes, where? ___________________________________________
Is this the patient’s first visit to a dentist? n Yes n No
If no, when was the patient’s last dental exam? ________________What was done at that appointment? _________________________________
When was the last time the patient had dental x-rays taken?...
Please use an “X” to mark questions.
Has the patient had any problem with dental treatment in the past? n n n
If yes, please describe what happened: _______________________________________________________________________________
Has the patient had any problems with teeth coming in or losing teeth? n n n
Does the patient use fluoride toothpaste when brushing teeth? n n n
How often are the patient’s teeth brushed? ______time(s) per _______At what time(s) of day are the teeth brushed? __________
Has the patient ever worn braces or other orthodontic appliances? n n n
Has the patient ever had a serious injury to the head, mouth or teeth? n n n
If yes, please describe what happened and when it happened: ____________________________________________________________...........................
Does the patient play any contact sports or participate in active recreational activities? n n n
If yes, please describe those activities here: ___________________________________________________________________________
Is your home water supply fluoridated? n n n
What is the patient’s primary source of drinking water? n Tap n Bottled n Filtered n Well
Does the patient take fluoride supplements? n n n
Does/did the patient use a pacifier or suck his/her thumb or fingers? n n n
At what age did the patient stop breastfeeding? __________At what age did the patient stop bottle feeding? __________
Has the patient ever experienced any sleep-related breathing disorders? n Mouth breathing n Snoring n Trouble breathing during sleep
© 2021 American Dental Association Form S70721 To reorder call 800.947.4746 or go to ADAcatalog.org.
Today’s Date: ___________________________________
Dental Claim Form (2024 Version)
The ADA Dental Claim Form was revised for 2024 with editorial
changes, additional fields to document treatment provided
by a locum tenens dentist and the patient’s last SRP date and
to update provider specialty coding information. Revisions to
the current version harmonize data content with the HIPAA
standard electronic claim transaction (837D). This is the
most recent edition of the form and includes one pad of 100,
8.5" x 11" sheets. The downloadable version of the form allows
immediate access and requires no shipping not for online use.
J43024 (shown) One pad of 100 sheets, 8.5” x 11”
Members $16.95 Retail $24.95
J43024T Downloadable PDF
Members $24.95 Retail $34.95
J43124 Two-part carbonless, one pad of 100 sheets, 8.5” x 11”
Members $24.95 Retail $34.95
J43224 Bond stock, one pad of 250 sheets, 8.5” x 11”
Members $32.95 Retail $47.95
J43224L Loose-leaf, bond stock, pack of 250
Members $32.95 Retail $47.95
J43424 (shown) Bond in red ink, one pad of 100 sheets, 8.5” x 11”
Members $16.95 Retail $24.95
J43524T Downloadable PDF in Spanish
Members $24.95 Retail $34.95
ADA Patient Health History Forms
The ADA Patient Dental and Medical Health History
Information Form features a clear, two-sided layout and
simple wording that 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.
S50021 Patient Dental &Medical Health History Information Form
One pad of 100 sheets, 8.5” x 11”
Members $19.95 Retail $29.95
S50121 Spanish |Patient Dental &Medical Health History
Information Form
One pad of 100 sheets, 8.5” x 11”
Members $19.95 Retail $29.95
S70721 (shown) Child’s Dental and Medical Health History
Information Form
One pad of 100 sheets, 8.5” x 11”
Members $19.95 Retail $29.95
Easy-to-use and easy-to-fill-out ADA forms
make information gathering simple for your team.
RECORD OF SERVICES PROVIDED
24. Procedure Date (MM/DD/CCYY)
25. Area
of Oral Cavity
26.
Tooth System
27. Tooth Number(s) or Letter(s) 28. Tooth Surface 29. Procedure Code 29a. Diag. Pointer 29b. Qty. 30. Description 31. Fee
1
2
3
4
5
6
7
8
9
10
33. Missing Teeth Information (Place an “X” on each missing tooth.) 34. Diagnosis Code List Qualifier (ICD-10 =AB )31a. Other
Fee(s) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 34a. Diagnosis Code(s) A _________________C _________________
32 31 30 29 28 27 26 25 24 23 22 21 20 18 17 (Primary diagnosis in “A”) B _________________D _________________32. Total Fee
35. Remarks
AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by
law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all
or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure
of my protected health information to carry out payment activities in connection with this claim. X _____________________________________________________________________________Patient/Guardian Signature Date
38. Place of Treatment n (e.g. 11=office 22=O/P Hospital)
(Use “Place of Service Codes for Professional Claims”)
39. Enclosures (Y or N)
40. Is Treatment for Orthodontics?
No (Skip 41-42) Yes (Complete 41-42)
41. Date Appliance Placed (MM/DD/CCYY)
42. Months of Treatment 43. Replacement of Prosthesis
No Yes (Complete 44)
44. Date of Prior Placement (MM/DD/CCYY)
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly
to the below named dentist or dental entity.
X _____________________________________________________________________________
Subscriber Signature Date
45. Treatment Resulting from
Occupational illness/injury Auto accident Other accident
46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State
BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not
submitting claim on behalf of the patient or insured/subscriber.)
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require
multiple visits) or have been completed.
X________________________________________________________________________________
Signed (Treating Dentist) Date
48. Name, Address, City, State, Zip
54. NPI 55. License Number
56. Address, City, State, Zip Code 56a. Provider Specialty Code
49. 50. License Number 51. SSN or TIN
52. Phone
Number ()-52a. Additional
Provider ID
57. Phone
Number ()-58. Additional
Provider ID
HEADER INFORMATION
1. Type of Transaction (Mark all applicable boxes)
Statement of Actual Services Request for Predetermination/Preauthorization
EPSDT /Title 2. Claim
Predetermination/Preauthorization Number
DENTAL BENEFIT PLAN INFORMATION
3. Company/Plan Name, Address, City, State, Zip Code
OTHER COVERAGE (Mark applicable box and complete items 5-11. INFORMATION
If none, leave blank.)
4. Dental? Medical? (If both, complete 5-11 for dental only.)
5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix)
6. Date of Birth (MM/DD/CCYY) 7. Gender
M F U
8.Policyholder/Subscriber ID (Assigned by Plan)
9. Plan/Group Number 10. (MM/DD/CCYY) Patient’s Relationship to Person named in #5
Self Spouse Dependent Other
11. Other Insurance Company/Dental Benefit Plan Name, Zip Code
POLICYHOLDER/SUBSCRIBER INFORMATION (Assigned by Plan Named in #3)
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip 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 Other
19. Reserved For Future
Use
20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
21. Policyholder/Subscriber
Date of Birth (MM/DD/CCYY) 22. Gender
M F U
23. Patient ID/Account #(Assigned by Dentist)
©2019 American Dental Association
J434 (Same as ADA Dental Claim Form – J430, J431, J432, J433, J430D)
Dental Claim Form
To reorder call 800.947.4746
or go online at ADAcatalog.org
RECORD OF SERVICES PROVIDED
24. Procedure Date
(MM/DD/CCYY) 25. Area
of Oral Cavity
26.
Tooth System 27. Tooth Number(s)
or Letter(s) 28. Tooth Surface 29. Procedure Code 29a. Diag.
29b.
Qty.
30. Description19
31. Fee
1
2
3
4
5
6
7
8
9
10
33. Missing Teeth Information (Place an “X” on each missing tooth.)
34 .Diagnosis Code List nn
(=)
31a. Other Fee(s)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
34 a. Diagnosis Code(s)
A _________________
C _________________
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 (Primary diagnosis in “A”)
B _________________Code
D _________________
32. Total Fee
35. Remarks
AUTHORIZATIONS
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for and not paid by my
benefit plan, unless prohibited by the my all a of I to of health information to carry out payment in this
X _____________________________________________________________________________Patient/Guardian Signature Date
37. I hereby authorize and direct payment of the dental benefits oth
erwise payable to me, directly
below or
X _____________________________________________________________________________Subscriber Signature Date OR DENTAL ENTITY
(Leave blank if dentist or dental entity is not submitting claim on behalf of the or 48. Zip Code
49. NPI
50. License Number
51. SSN or TIN
52. Phone
Number ()-
52a. Additional Provider ID
ANCILLARY CLAIM/TREATMENT INFORMATION
(alll dates format)
38. of Treatment n (e.g. 11=office
)(Use “Place Codes
39. Enclosures (Y or N)
SRP
40. Is ONPI
rthodontics? n
No n Yes 41. Date Appliance Placed (MM/DD/CCYY) 42. Months of
43. Replaceme nt of Prosthesis n
No n
Yes (Complete 44) 44. Date of Prior Placement (MM/DD/CCYY) 45. Treatment Resulting from n Occupational illness/injury n
Auto accident n
Other accident
46. Date of Accident (MM/DD/CCYY) 47. INFORMATION
Auto Accident State TREATMENT
53. I hereby certify that the procedures as by date are in progress (for that require or been X ________________________________________________________________________________Signed (Treating Dentist) Date 53a. Dentist? n NPI
55. License Number 56. Address, City, State, Zip Code
56a. Provider Specialty Code
57. Phone Number ()-
58. Additional
Provider ID
©2024 American Association (Same as ADA Dental Claim Form – J43224,
To reorder call 800.947.4746 go
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HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes)
n Request for Predetermination/Preauthorization
n Statement of Actual Services n
EPSDT /Title 2. Predetermination/Preauthorization Number DENTAL BENEFIT PLAN INFORMATION 3. Name, City, State, Zip Code
3a. Payer ID OTHER COVERAGE (Mark applicable box and complete items 5-11. If none, leave blank.) 4. Dental? n n (If both, complete 5-11 for dental only.) 5. Name of Policyholder/Subscriber in
6. Date of Birth (MM/DD/CCYY)
7. Gender nM nFnU 8.Policyholder/Subscriber ID (Assigned by Plan) 9. Plan/Group Number
10. Patient’s Relationship to Person named in #5 n n
Spouse n
Dependent n
Other
11. Other Insurance Company/Dental Name,
11a. Other Payer ID
POLICYHOLDER/SUBSCRIBER
(Assigned by Plan Named in #3)
Suffix), City, State, Zip
13. of Birth
14. Gender nAddress,nCity,nState,
M F U
15. ID by 16. Number
17. Employer Name PATIENT INFORMATION 18. to in #12 Above n
Self n
Spouse n
Dependent Child n
Other 19. Reserved For Future Use 20. Name (Last, First, Initial, City, Zip Code
21. Date of Birth (MM/DD/CCYY)
22. Gender nMnFnU 23. Patient ID/Account #(Assigned by Dentist)
Dental FormXIX
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Save 20% when you order 5+ packs!
34 ORDER BY PHONE: 800.947.4746
Patient
Education
Give patients and their caregivers access to
science-based advice that reinforces your
diagnosis and treatment plan. Our print
and digital products make it easy to
share the knowledge they need for
excellent, sustainable oral health.
Nutrition and Oral Health
W22824 |See page 51
Pain Management for Dental Patients
W25124 |See page 53
The Pediatric Chairside Instructor
W01524BT |See page 41
35 ORDER ONLINE: ADASTORE.ORG
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A nuestros pacientes: tenga en cuenta que podemos formular preguntas de seguimiento para asegurarnos de que tengamos toda la información que necesitamos a fin
de poder tratarlo.
INFORMACIÓN DEL PACIENTE
Apellido: Nombre: Segundo nombre:
Teléfono particular: Teléfono celular: Teléfono laboral:
Dirección de correo electrónico:
Domicilio postal: Ciudad: Estado: Código postal:
Fecha de nacimiento: //Sexo:
Ocupación:
Contacto de emergencia: Nombre: Relación: Teléfono:
Si está completando el formulario en nombre de otra persona, ¿cuál es su nombre y la relación con esa persona? Nombre: _____________________Relación: __________________
Si firma este formulario en calidad de representante personal del paciente: Declaro y garantizo que tengo pleno derecho y autoridad legal para consentir la realización de cualquier
procedimiento a este paciente. Si por alguna razón ya no tengo tal derecho y autoridad legal, lo notificaré de inmediato por escrito al consultorio.
HISTORIAL DENTAL Y SÍNTOMAS
¿Cuál es el motivo de la visita de hoy?
¿Actualmente experimenta algún dolor o malestar dental? Sí No Si es así, ¿dónde?
¿Cuándo fue el último examen dental? //¿Qué se llevó a cabo en esa cita?
¿Cuándo fue la última vez que le realizaron radiografías dentales?
Marque la casilla con una «X» SOLO si se aplica a usted.
¿Le cuesta abrir la boca? ......................................................
¿Le duele al masticar, morder o tragar? ..........................................
¿Le sangran las encías cuando se cepilla o usa hilo dental? .........................
¿Se ha sometido alguna vez a tratamientos periodontales (de encías) como
destartraje y alisado radicular? .................................................
¿Tiene, o alguna vez ha tenido, llagas o protuberancias en la boca? .................
¿Aprieta o hace rechinar los dientes? ............................................
¿Siente algún chasquido, crujido o dolor en la mandíbula? ..........................
¿Tiene dolores de oído o de cuello? .............................................
¿El tratamiento dental lo pone nervioso? ........................................
¿Alguna vez ha experimentado alguno de estos trastornos respiratorios relacionados
con el sueño? ................................................................
Respiración por boca Ronquido Dificultad para respirar durante el sueño
¿Alguna vez ha sufrido una lesión grave en la cabeza o la boca? ....................
Si es así, describa lo ocurrido y cuándo ocurrió: ___________________________________
____________________________________________________________________________
¿Ha tenido problemas con el tratamiento dental en el pasado? .....................
Si es así, describa lo ocurrido: __________________________________________________
____________________________________________________________________________
¿Alguna vez ha tenido una reacción o un problema con la anestesia dental? ..........
Si es así, describa lo ocurrido: __________________________________________________
____________________________________________________________________________
¿No le gusta su sonrisa? ......................................................
Si es así, ¿por qué? Marque donde corresponda:
El color de sus dientes La forma de sus dientes La posición de sus dientes
Otros. Describa: _________________________________________________________
MEDICACIONES Y OTROS PRODUCTOS/OTRAS SUSTANCIAS
Marque las respuestas a las siguientes preguntas con una «X». Sí No ?
¿Toma algún anticoagulante (como warfarina [Coumadin®], rivaroxabán [Xarelto®], dabigatrán [Pradaxa®], clopidogrel [Plavix®], heparina o aspirina)? .................
Si es así, ¿qué medicación toma? _______________________________________________________________________________________________________________
¿Toma alguna medicación para tratar la osteoporosis o la enfermedad de Paget? .............................................................................
Algunos medicamentos que se recetan comúnmente incluyen alendronato (Fosamax®), risedronato (Actonel®), ibandronato (Boniva®), zolendronato (Reclast®) y denosumab (Prolia®).
Si es así, ¿qué medicación toma? _______________________________________________________________________________________________________________?
¿Usa, o tiene previsto usar, medicación intravenosa (IV) para tratar el dolor de huesos, la hipercalcemia o las complicaciones óseas derivadas de la enfermedad de Paget,
el mieloma múltiple o el cáncer metastásico? ............................................................................................................
Algunos medicamentos que se recetan comúnmente incluyen denosumab (Xgeva®), pamidronato (Aredia®) o zolendronato (Zometa®).
Si es así, ¿qué medicación toma? _________________________________________________¿Hace cuántos años que la toma? _______________________________
¿Recibe terapia de sustitución hormonal?. ...............................................................................................................
¿Consume algún tipo de tabaco o productos de nicotina (cigarrillo, cigarro, rapé, tabaco para mascar, bidi)? .....................................................
¿Utiliza productos de vapeo?. ...........................................................................................................................
¿Cuántas bebidas alcohólicas consume por semana? __________________
¿Consume sustancias controladas (drogas), incluida la marihuana, por motivos medicinales o recreativos? .......................................................
Si es así, ¿qué sustancias?___________________________ Si es así, ¿con qué frecuencia? A diario Varias veces por semana Todas las semanas A veces
¿La sustancia fue recetada por un médico? Sí No Si es así, ¿por qué razones? ____________________________________________________________
¿Toma algún otro medicamento recetado o de venta libre, vitaminas, hierbas o suplementos? .............................................................
Si es así, enumérelos aquí e incluya información sobre la cantidad y la frecuencia de uso de cada uno _____________________________________________________
SOLO PARA MUJERES:
¿Toma píldoras anticonceptivas? ........................................................................................................................
¿Está embarazada? Si es así, incluya la cantidad de semanas: _____________________________.................................................................
¿Está en el periodo de lactancia? Si es así, incluya la cantidad de semanas: ________________......................................
© 2021 American Dental Association Formulario S50121 Para volver a pedirlo, llame al 800.947.4746 o visite ADAcatalog.org.
Fecha de hoy: ___________________________________Patient Dental &Medical Health History Information
To our patients: 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:
Cell Phone:
Work Phone:
Mailing Address:
City:
State:
Zip:
Date of Birth: //
Gender:
Occupation:
Emergency Contact: Name:
Relationship:
Phone:
If you this form for another person, what is your name and to that person? Name:
__________________________________
Relationship: _______________
this the I I full legal and authority to to the performance of on this for reason such I the DENTAL &What is the for your visit today?we Are any dental pain or discomfort?
n Yes n No If yes, where?
last //
What was done at that appointment? last had dental Please mark an in the box if this applies to you.
Is it hard .................................................
n
Does it hurt to chew, bite or
..........................................Do
.........................nn you ever had periodontal (gum)
........n
Do you or ever any sores or growths in
...........n
clench grind your
...................................
n .................................
n .........................................Does dental treatment make you
......................................nn
.........n
n Snoring n breathing during sleep
Have you ever had a serious injury to your head or mouth?
........................If
______________________n ____________________________________________________________________________Have you ever had problems with dental treatment in the
n
If ____________________________________________________________________________....................dentalwith,__________________________________________problemorto,reactionahadeveryou Have If
__________________________________________..............____________________________________________________________________________.n Are you unhappy with your smile?.
.............................................n If why? all apply:
n The color of your teeth
n The shape of your teeth
n The position of your teeth
n Other. Please describe: ___________________________________________________
&PRODUCTS/SUBSTANCES the
Yes No ?
Are you taking any blood thinners Warfarin, rivaroxaban (Xarelto®), dabigatran or
.............n n n
_________________________________________________________________________________________________________to
osteoporosis or Paget’s disease? ..........................................................
n n n
If yes, what medication are you taking? Are or an
IV to treat bone pain, hypercalcemia
or metastatic ................................
n n n
If ___________________________________________
How many years have you been taking it?
________________________
Are taking replacements.? .........................................................
n n n
or products
......................................................
n n n
Do use .............................
n n n
How many
__________________
you or
............................................
n n n
________________________________
If yes, how often is your use?
n Daily n
n Weekly n Occasionally
n Yes n No If ______________________________________________________________prescriptions over-the-counter
................................
n n n
use
__________________________________________________..
Taking birth control pills? .....................................................................................
n n n
___________________................................................................................................
n n n
?If
_____________________..................................................................................................
n n n
800.947.4746 go ADAcatalog.org.
Today’s Date: ___________________________________
Child’s Dental &Medical Health History Information
To the parents/guardians of the patient: Please know that we may ask all of the information we need in
the patient.
PATIENT INFORMATION
Last Name: First Name: 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 following question.
Have you (the adult) or the patient (the child) had? n A cough that’s lasted longer than three weeks n A cough that produces blood
n Active Tuberculosis
to the receptionist right away if you marked “Yes” any these items.
PATIENT’S DENTAL HEALTH HISTORY
What is the reason for your visit today?
How would you describe the patient’s oral health? n Excellent n Good n Fair n Poor
Does the patient currently have any dental pain or discomfort? n Yes n No If yes, where? ___________________________________________
Is this the patient’s first visit to a dentist? n Yes n No
If no, when was the patient’s last dental exam? ________________What was done at that appointment? _________________________________
When was the last time the patient had dental x-rays taken?...
Please use an “X” to mark questions.
Has the patient had any problem with dental treatment in the past? n n n
If yes, please describe what happened: _______________________________________________________________________________
Has the patient had any problems with teeth coming in or losing teeth? n n n
Does the patient use fluoride toothpaste when brushing teeth? n n n
How often are the patient’s teeth brushed? ______time(s) per _______At what time(s) of day are the teeth brushed? __________
Has the patient ever worn braces or other orthodontic appliances? n n n
Has the patient ever had a serious injury to the head, mouth or teeth? n n n
If yes, please describe what happened and when it happened: ____________________________________________________________...........................
Does the patient play any contact sports or participate in active recreational activities? n n n
If yes, please describe those activities here: ___________________________________________________________________________
Is your home water supply fluoridated? n n n
What is the patient’s primary source of drinking water? n Tap n Bottled n Filtered n Well
Does the patient take fluoride supplements? n n n
Does/did the patient use a pacifier or suck his/her thumb or fingers? n n n
At what age did the patient stop breastfeeding? __________At what age did the patient stop bottle feeding? __________
Has the patient ever experienced any sleep-related breathing disorders? n Mouth breathing n Snoring n Trouble breathing during sleep
© 2021 American Dental Association Form S70721 To reorder call 800.947.4746 or go to ADAcatalog.org.
Today’s Date: ___________________________________
Dental Claim Form (2024 Version)
The ADA Dental Claim Form was revised for 2024 with editorial
changes, additional fields to document treatment provided
by a locum tenens dentist and the patient’s last SRP date and
to update provider specialty coding information. Revisions to
the current version harmonize data content with the HIPAA
standard electronic claim transaction (837D). This is the
most recent edition of the form and includes one pad of 100,
8.5" x 11" sheets. The downloadable version of the form allows
immediate access and requires no shipping not for online use.
J43024 (shown) One pad of 100 sheets, 8.5” x 11”
Members $16.95 Retail $24.95
J43024T Downloadable PDF
Members $24.95 Retail $34.95
J43124 Two-part carbonless, one pad of 100 sheets, 8.5” x 11”
Members $24.95 Retail $34.95
J43224 Bond stock, one pad of 250 sheets, 8.5” x 11”
Members $32.95 Retail $47.95
J43224L Loose-leaf, bond stock, pack of 250
Members $32.95 Retail $47.95
J43424 (shown) Bond in red ink, one pad of 100 sheets, 8.5” x 11”
Members $16.95 Retail $24.95
J43524T Downloadable PDF in Spanish
Members $24.95 Retail $34.95
ADA Patient Health History Forms
The ADA Patient Dental and Medical Health History
Information Form features a clear, two-sided layout and
simple wording that 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.
S50021 Patient Dental &Medical Health History Information Form
One pad of 100 sheets, 8.5” x 11”
Members $19.95 Retail $29.95
S50121 Spanish |Patient Dental &Medical Health History
Information Form
One pad of 100 sheets, 8.5” x 11”
Members $19.95 Retail $29.95
S70721 (shown) Child’s Dental and Medical Health History
Information Form
One pad of 100 sheets, 8.5” x 11”
Members $19.95 Retail $29.95
Easy-to-use and easy-to-fill-out ADA forms
make information gathering simple for your team.
RECORD OF SERVICES PROVIDED
24. Procedure Date (MM/DD/CCYY)
25. Area
of Oral Cavity
26.
Tooth System
27. Tooth Number(s) or Letter(s) 28. Tooth Surface 29. Procedure Code 29a. Diag. Pointer 29b. Qty. 30. Description 31. Fee
1
2
3
4
5
6
7
8
9
10
33. Missing Teeth Information (Place an “X” on each missing tooth.) 34. Diagnosis Code List Qualifier (ICD-10 =AB )31a. Other
Fee(s) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 34a. Diagnosis Code(s) A _________________C _________________
32 31 30 29 28 27 26 25 24 23 22 21 20 18 17 (Primary diagnosis in “A”) B _________________D _________________32. Total Fee
35. Remarks
AUTHORIZATIONS ANCILLARY CLAIM/TREATMENT INFORMATION
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by
law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all
or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure
of my protected health information to carry out payment activities in connection with this claim. X _____________________________________________________________________________Patient/Guardian Signature Date
38. Place of Treatment n (e.g. 11=office 22=O/P Hospital)
(Use “Place of Service Codes for Professional Claims”)
39. Enclosures (Y or N)
40. Is Treatment for Orthodontics?
No (Skip 41-42) Yes (Complete 41-42)
41. Date Appliance Placed (MM/DD/CCYY)
42. Months of Treatment 43. Replacement of Prosthesis
No Yes (Complete 44)
44. Date of Prior Placement (MM/DD/CCYY)
37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly
to the below named dentist or dental entity.
X _____________________________________________________________________________
Subscriber Signature Date
45. Treatment Resulting from
Occupational illness/injury Auto accident Other accident
46. Date of Accident (MM/DD/CCYY) 47. Auto Accident State
BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not
submitting claim on behalf of the patient or insured/subscriber.)
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require
multiple visits) or have been completed.
X________________________________________________________________________________
Signed (Treating Dentist) Date
48. Name, Address, City, State, Zip
54. NPI 55. License Number
56. Address, City, State, Zip Code 56a. Provider Specialty Code
49. 50. License Number 51. SSN or TIN
52. Phone
Number ()-52a. Additional
Provider ID
57. Phone
Number ()-58. Additional
Provider ID
HEADER INFORMATION
1. Type of Transaction (Mark all applicable boxes)
Statement of Actual Services Request for Predetermination/Preauthorization
EPSDT /Title 2. Claim
Predetermination/Preauthorization Number
DENTAL BENEFIT PLAN INFORMATION
3. Company/Plan Name, Address, City, State, Zip Code
OTHER COVERAGE (Mark applicable box and complete items 5-11. INFORMATION
If none, leave blank.)
4. Dental? Medical? (If both, complete 5-11 for dental only.)
5. Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix)
6. Date of Birth (MM/DD/CCYY) 7. Gender
M F U
8.Policyholder/Subscriber ID (Assigned by Plan)
9. Plan/Group Number 10. (MM/DD/CCYY) Patient’s Relationship to Person named in #5
Self Spouse Dependent Other
11. Other Insurance Company/Dental Benefit Plan Name, Zip Code
POLICYHOLDER/SUBSCRIBER INFORMATION (Assigned by Plan Named in #3)
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip 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 Other
19. Reserved For Future
Use
20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code
21. Policyholder/Subscriber
Date of Birth (MM/DD/CCYY) 22. Gender
M F U
23. Patient ID/Account #(Assigned by Dentist)
©2019 American Dental Association
J434 (Same as ADA Dental Claim Form – J430, J431, J432, J433, J430D)
Dental Claim Form
To reorder call 800.947.4746
or go online at ADAcatalog.org
RECORD OF SERVICES PROVIDED
24. Procedure Date
(MM/DD/CCYY) 25. Area
of Oral Cavity
26.
Tooth System 27. Tooth Number(s)
or Letter(s) 28. Tooth Surface 29. Procedure Code 29a. Diag.
29b.
Qty.
30. Description19
31. Fee
1
2
3
4
5
6
7
8
9
10
33. Missing Teeth Information (Place an “X” on each missing tooth.)
34 .Diagnosis Code List nn
(=)
31a. Other Fee(s)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
34 a. Diagnosis Code(s)
A _________________
C _________________
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 (Primary diagnosis in “A”)
B _________________Code
D _________________
32. Total Fee
35. Remarks
AUTHORIZATIONS
36. I have been informed of the treatment plan and associated fees. I agree to be responsible for and not paid by my
benefit plan, unless prohibited by the my all a of I to of health information to carry out payment in this
X _____________________________________________________________________________Patient/Guardian Signature Date
37. I hereby authorize and direct payment of the dental benefits oth
erwise payable to me, directly
below or
X _____________________________________________________________________________Subscriber Signature Date OR DENTAL ENTITY
(Leave blank if dentist or dental entity is not submitting claim on behalf of the or 48. Zip Code
49. NPI
50. License Number
51. SSN or TIN
52. Phone
Number ()-
52a. Additional Provider ID
ANCILLARY CLAIM/TREATMENT INFORMATION
(alll dates format)
38. of Treatment n (e.g. 11=office
)(Use “Place Codes
39. Enclosures (Y or N)
SRP
40. Is ONPI
rthodontics? n
No n Yes 41. Date Appliance Placed (MM/DD/CCYY) 42. Months of
43. Replaceme nt of Prosthesis n
No n
Yes (Complete 44) 44. Date of Prior Placement (MM/DD/CCYY) 45. Treatment Resulting from n Occupational illness/injury n
Auto accident n
Other accident
46. Date of Accident (MM/DD/CCYY) 47. INFORMATION
Auto Accident State TREATMENT
53. I hereby certify that the procedures as by date are in progress (for that require or been X ________________________________________________________________________________Signed (Treating Dentist) Date 53a. Dentist? n NPI
55. License Number 56. Address, City, State, Zip Code
56a. Provider Specialty Code
57. Phone Number ()-
58. Additional
Provider ID
©2024 American Association (Same as ADA Dental Claim Form – J43224,
To reorder call 800.947.4746 go
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HEADER INFORMATION 1. Type of Transaction (Mark all applicable boxes)
n Request for Predetermination/Preauthorization
n Statement of Actual Services n
EPSDT /Title 2. Predetermination/Preauthorization Number DENTAL BENEFIT PLAN INFORMATION 3. Name, City, State, Zip Code
3a. Payer ID OTHER COVERAGE (Mark applicable box and complete items 5-11. If none, leave blank.) 4. Dental? n n (If both, complete 5-11 for dental only.) 5. Name of Policyholder/Subscriber in
6. Date of Birth (MM/DD/CCYY)
7. Gender nM nFnU 8.Policyholder/Subscriber ID (Assigned by Plan) 9. Plan/Group Number
10. Patient’s Relationship to Person named in #5 n n
Spouse n
Dependent n
Other
11. Other Insurance Company/Dental Name,
11a. Other Payer ID
POLICYHOLDER/SUBSCRIBER
(Assigned by Plan Named in #3)
Suffix), City, State, Zip
13. of Birth
14. Gender nAddress,nCity,nState,
M F U
15. ID by 16. Number
17. Employer Name PATIENT INFORMATION 18. to in #12 Above n
Self n
Spouse n
Dependent Child n
Other 19. Reserved For Future Use 20. Name (Last, First, Initial, City, Zip Code
21. Date of Birth (MM/DD/CCYY)
22. Gender nMnFnU 23. Patient ID/Account #(Assigned by Dentist)
Dental FormXIX
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Save 20% when you order 5+ packs!
34 ORDER BY PHONE: 800.947.4746
Patient
Education
Give patients and their caregivers access to
science-based advice that reinforces your
diagnosis and treatment plan. Our print
and digital products make it easy to
share the knowledge they need for
excellent, sustainable oral health.
Nutrition and Oral Health
W22824 |See page 51
Pain Management for Dental Patients
W25124 |See page 53
The Pediatric Chairside Instructor
W01524BT |See page 41
35 ORDER ONLINE: ADASTORE.ORG
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