Today's Date:

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.

Birth Date:
Do you have any of the following diseases or problems:
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 contact the receptionist.
Dental Information
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you ever had periodontal(gum) treatement?
Have you ever had orthodontic treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated
Do you drink bottled or filtered water?
are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Date of your last dental exam
Date of last dental X-Rays
Medical Information
Are you now under the care of a physician? YesNo
Are you in good health? YesNo
Date of last physical exam:
Has there been any change in your general health within the past year? YesNo
Have you had a serious illness, operation or been hospitalized in the past 5 years? YesNo
Are you taking or have you recently taken any prescription or over the counter medicine(s)? YesNo
Do you wear contact lenses? YesNo
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? YesNo
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease? YesNo
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer? YesNo
Date treatment began:
Do you use controlled substances(drugs)? YesNo
Do you use tobacco (smoking, snuff, chew, bidis)? YesNo
If so, how interested are you in stopping?
Do you drink alcoholic beverages? YesNo
Are you allergic to or have you had a reaction to:
Local Anesthetics
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa Drugs
Codeine or other narcotics
Latex (Rubber)
Hay fever/seasonal
Please check your response to indicate if you have had any of the following diseases or problems:
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart
Unrepaired, cyanotic CHD(Congenital heart disease)
CHD Repaired (completely) in last 6 months
Repaired CHD with residual defects
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
Cardiovascular Disease
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Other congenital heart defects
Mitral valve prolapse
Rheumatic fever
Rheumatic heart disease
Abnormal bleeding
Blood transfusion
AIDS or HIV infection
Autoimmune Disease
Rheumatoid arthritis
Systemic lupus erythematosus
Sinus trouble
Cancer/Chemotherapy/Radiation treatment
Chest pain upon exertion
Chronic pain
Diabetes Type I or II
Eating disorder
Gastrointestinal disease
G.E. Reflux/persistent heartburn
Thyroid problems
Hepatitis, jaundice or liver disease
Fainting spells or seizures
Neurological disorders
Recurrent infections
Kidney problems
Persistent swollen glands in neck
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Excessive Urination
Has a physician or previous dentist recommend that you take antibiotics prior to your dental treatment? YesNo
Do you have any disease, condition, or problem not listed above that you think I should know about? YesNo
HIPAA Notice of Privacy Practices
     This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review the following carefully.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. The Act gives you, the patient, significant new rights to understand and control how your information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records for several purposes, including treatment, payment, defense of legal matters, to family and friends, and health care operations:
  • Treatment includes providing, coordinating, and/or managing health care related services by one or more health care providers. An example of this would include teeth cleaning services.
  • Payment includes such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a claim for your visit to your insurance company for payment.
  • Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information.
  • To Your Family and Friends: We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare. Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.
In some limited situations, the law allows or requires us to use/disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
  • When a state or federal law mandates that certain health information be reported for a specific purpose
  • For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices
  • Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence
  • Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws
  • Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies
  • Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else
  • Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations
  • Uses or disclosures for health-related research
  • Uses and disclosures to prevent a serious threat to health or safety
  • Uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service
  • Disclosures of de-identified information
  • Disclosures relating to worker's compensation programs
  • Disclosures of a "limited data set" for research, public health, or healthcare operations
  • Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures
  • Disclosures to "business associations" who perform healthcare operations for our office and who commit to respect the privacy of your health information
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. If you wish to be omitted from any mailings please provide a written notice. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
  • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health information and provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of September 20, 2016, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect.

We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

If you think that we have not properly respected the privacy of your health information or that your privacy protections have been violated, you have the right to file a written complaint to us or the U.S. Department of Health and Human Services, Office for Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

For more information about HIPAA and/or to file a complaint, please call or visit or office or contact:
The U.S. Department of Health & Human Services, Office for Civil Rights
200 Independence Avenue, S.W.
Washington D.C. 20201
(202) 619-0257 Toll Free: 1-877-696-6775

HIPAA Patient 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 (a.k.a. HIPAA or The Healthcare Privacy Act). I understand that by signing this consent, I authorize (Doctor or Practice Name) to use and/or disclose my protected health information to carry out the following:
  • Treatment which includes direct and/or indirect treatment by other healthcare providers involved in my treatment.
  • Obtaining payment from third party payers, i.e. my dental and/or medical insurance company/companies.
  • The day to day healthcare operations of your dental 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 personal 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 request 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 healthcare operations, but that you are not required to agree to use 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 will not be affected.
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 healthhistory 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 forthabove 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 nottake because of errors or omissions that I may have made in the completion of this form.