Patient History Form (Child)

Your Email:

Today’s Date:

Patient’s Dentist:

Patient’s Name:

Age:

Birth date:

Sex:
 M  F

Prefers to be called:

Referred by:

Address:

City:

State:

Zip:

Phone:

School:

Grade:

Hobbies:

BILLING PARTY INFORMATION

Father’s Name:

Cell Phone:

Home Phone:

Email:

Mailing Address (if different than patient's address)

Address:

City:

State:

Zip:

Father’s Employer:

Occupation:

Work Phone:

SS#:

DOB:

Insurance Company:

ID#:

Group #:

Benefits
 Primary Benefit  Secondary Benefit
Ortho Benefits:  Yes  No - If Yes, Amount: $

Mother’s Name:

Cell Phone:

Home Phone:

Email:

Mailing Address (if different than patient's address)

Address:

City:

State:

Zip:

Mothers’s Employer:

Occupation:

Work Phone:

SS#:

Mothers’s DOB:

Insurance Company:

ID#:

Group #:

Benefits
 Primary Benefit  Secondary Benefit
Ortho Benefits:  Yes  No - If Yes, Amount: $

Parents' Marital Status:  Married  Single  Divorced  Separated  Widowed

Patient Siblings:
Name: DOB:
Name: DOB:
Name: DOB:
Name: DOB:

DENTAL HISTORY

Date of Last Visit:

1. Have there been any injuries to the face, mouth or teeth?
    Yes  No

2. Has the patient had or presently have any of the following habits?
    Thumb or Finger sucking  Lip Biting  Snoring  Grinding of teeth at night  Mouth Breathing  None

3. Has the patient been informed of any missing or extra permanent teeth?
    Yes  No

4. Is the patient aware of sores, lumps or irritated areas in the mouth?
    Yes  No

5. Has the patient ever been treated for:
    Bad Bite  TMJ  Periodontal disease  No
   If so, by whom:

6. Does the patient have any speech problems?
    Yes  No

7. Is the patient frightened or anxious about orthodontic treatment?
    Yes  No

8. What aspect of dental treatment is the patient most concerned with?
    Quality  Cost  Discomfort  Time

9. Reason for Consultation (Chief Concern):

10. Has there ever been any orthodontic treatment for any other member of the family?
     Yes  No - Are you satisfied with the result?  Yes  No

    Mother treated by Dr.
    

    Father treated by Dr.
    

    Sister treated by Dr.
    

    Brother treated by Dr.
    

MEDICAL HISTORY

1. Is the patient’s general health good at this time?
    Yes  No

2. What is the name of the family physician?
   
   Date of last physical:
   

3. Is the patient under the care of a physician at this time?
    Yes  No - Explain:

4. Is the patient taking any medication?
    Yes  No - Name:

5. Is the patient allergic to any medication? (Penicillin, Sulfa, etc.)
    Yes  No - Name:

6. Has the patient had tonsils and/or adenoids removed?
    Yes  No - Age:

7. Has the patient ever had a serious illness or been hospitalized?
    Yes  No - Explain:

8. Does the patient have any special problems not listed?
    Yes  No - Explain:

9. Has the patient ever been advised by their physician to take an antibiotic prior to any dental treatments?
    Yes  No - If yes, antibiotic name and method:

10. What is the patient’s approximate height?
    
    Weight?
    

11. Has the patient shown signs of increased growth recently?
     Yes  No

12. Has the patient reached puberty?  Yes  No
    Girls - started menstruating?  Yes  No
    Boys - voice changed?  Yes  No

13. Father’s present height:
    
    Mother’s present height:
    
14. Older brother’s height:
    
    Older sister’s height:
    

DOES THE PATIENT NOW, OR HAVE THEY EVER HAD ANY OF THE FOLLOWING?
 TUBERCULOSIS INFLAMMATORY RHEUMATISM
 ENDOCARDITIS ARTHRITIS
 HEART CONDITION ULCERS
 HEART PACEMAKER STROKE
 PSYCHIATRIC TREATMENT ANEMIA
 HEART ANGINA ASTHMA
 HEART ATTACK (CORONARY) EPILEPSY
 MITRAL VALVE PROLAPSE GLAUCOMA
 CONGENITAL HEART DISEASE FAINTING SPELLS
 ARTIFICAL HEART VALVE ADD
 HEART MURMUR KIDNEY TROUBLE
 RHEUMATIC FEVER LIVER DISEASE
 PROSTHETIC (ARTIFICAL) JOINT DRUG ADDICTION
 X-RAY/RADIATION (CANCER) THERAPY HEADACHES
 AIDS OR H.I.V. POSITIVE EARACHES
 DIABETES JAW CLICKING
 RESPIRATORY LUNG DISEASE ALLERGIES
 HIGH BLOOD PRESSURE ALLERGIES TO METAL
 LOW BLOOD PRESSURE JAW PAIN
 VENEREAL DISEASE TONSILLITIS
 HERPES (ORAL-COLD SORES) EMOTIONAL PROBLEMS
 BLOOD DISORDERS/BLEEDING PROBLEMS

HEART SURGERY  Yes  No - If yes, date?
HEPATITIS  Yes  No - If yes, type?
 OTHER:

*You can only submit this online form by acknowledging the following*
YES - I have reviewed the medical history section and completed it to the best of my knowledge.

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION NOT DISCLOSED. I understand that when appropriate a credit report may be obtained.

Name of parent or guardian

Date

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4-14-03, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider treatment to you.

Payment: We may use and disclose health information to obtain payment for services we provide to you.

Healthcare operations: We may use and disclose healthcare information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating the practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give use written authorization to use your health information or to disclose it to anyone for purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Friends and Family: We must disclose your health information to you, as described in the Patient Rights Section of this Notice. 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, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, you general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also 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.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are possible victim of abuse, neglect, or domestic violence, or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or the health and safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with an appointment reminder (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge on a cost- based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure).

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last six years, but not before April 14, 2003. If you request this accounting more once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternate locations. (You must make your request in writing). You request must specify the alternative means or locations, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny requests under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about your access to your health information or in response to a request you made to amend or restrict or disclosure of your health information or to have us communicate with you by an alternate means or at an alternate location, you may complain to us by using the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Dr. John Murray, DDS

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You can only submit this online form by acknowledging receipt of the above notice*

YES - I, (parent or guardian name) ,
have received and seen this online copy of this office’s Notice of Privacy Practices.

Patient Name

Guardian Name

Date