Health History Update | O'Neal Smiles

Health Information Update Patient Name: Birthdate:

Are you under a physician's care now? Yes No
If yes, please explain:

Are you allergic to any of the following Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal
Latex Sulfa drugs Other

Do you have, or have you had, any of the following

AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding

Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease

Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice

Other:

Have you been admitted to a hospital or needed emergency care during the past two years?
Yes No
If yes, please explain:

Do you use tobacco? Yes No

Are you taking any medications, pills, or drugs? Yes No
If yes, please explain:

Women: Are you Pregnant/Trying to get pregnant Taking oral contraceptives Nursing

Do you have any health problems that need further clarification? Yes No
If yes, please explain:

Dental History Date of last dental visit:
Reason for this visit:

Have you ever had any complications following dental treatment? Yes No
If yes, please explain:

Do you have any concerns about previous dental care or this dental visit? Yes No
If yes, please explain:

Do your gums bleed? Yes No

Are your teeth loose? Yes No

Have you ever been told that you have bad breath? Yes No

Are your teeth sensitive to (check all that apply): Sweets Cold Heat Pressure

Do you feel your teeth are starting to get longer? Yes No

Do you get food stuck between your teeth easily? Yes No

Do you ever experience tooth pain that is relieved by biting down on the affected area? Yes No

Please check any statement that you agree with about your smile:

I wish my teeth were whiter.
I wish I had a bigger smile.
I think some of my teeth are too small.
I think some of my teeth are too large.
I wish my teeth were straighter.
My gums show too much when I smile.
I think there is too much space between some of my teeth.
Because I am not totally pleased with my smile, I sometimes hesitate to smile.
I have often wished I could change some of the features of my smile.
I think I need to do a better job of protecting the health of my smile.

Dental Insurance

As a courtesy to our patients we are happy to submit claims to your PRIMARY dental insurance company. Your dental benefits are dependent on the plan that you or your employer have selected and it is important that YOU BECOME AN EXPERT ON YOUR PARTICULAR INSURANCE PLAN BENEFITS; especially to the extent that it will be a factor in your treatment decisions.

We ask that you…

Take care of your portion of estimated fees and any applicable deductibles for your treatment on or before your appointment date.
Update us immediately when your insurance coverage changes.
Pay any amount due after insurance has paid their portion.

We will…

Submit your insurance claims to your PRIMARY INSURANCE COMPANY ONLY.
Provide necessary documentation to you, the patient, the facilitate your secondary claim, such as x-rays, narratives and primary carrier explanation of benefits.
Be sensitive to your budget and help with creative financial options when necessary.
Help you understand the process so everything goes smoothly for you.

The following information is required to allow us to process insurance for our patients:

Primary Carrier Name & Address:
Patient relationship to Employee: Subscriber Birthdate:
Subscriber Name & Address:
Subscriber ID#: Subscriber Gender: M F
Subscriber's Employer: Group/Policy#

Authorizations

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.

I have been informed of O'Neal Smiles, LLC financial and appointment policies. I agree to be responsible for all fees for services and materials incurred during the course of my treatment. To the extent permitted by law, I consent to the use of my protected health information by O'Neal Smiles, LLC to carry out payment activities in connection with my care.

I hereby authorize payment of the insurance benefits otherwise payable to me directly to O'Neal Smiles, LLC.

Signature of Patient, Parent or Guardian: Date: