Health History Form
       

KERRY JOHNSON, D.D.S.

Thank you for visiting our office.  We want your visit to be pleasant and comfortable.  Please help us by completing this form. 

All of this information is completely confidential.

Patient Information

Full Patient
Name: First MI Last Preferred Name

Home Address   Home Phone   Work Phone
City           State                Zip Code
E-mail Address          Cell Phone      
Sex: 
MaleFemale
    Birth date 

Marital Status 
SingleMarriedWidowedSeparatedDivorced

Patient Social Security #         Patient Employer & Occupation                            
Spouse’s Name         Spouse’s Employer & Occupation 
Emergency contact name & phone number 
How did you hear about our office?
 

Responsible Party Information

Person Financially Responsible        Relation to patient
Home Address Home Phone
City  State   Zip Code Work Phone    
Birth Date     SS#  Employer    

Dental Insurance Information

Is patient covered by dental insurance?    
YesNo
  (If yes, please complete the following:)
Policy Holder Name    Relation to patient
Home Address Home Phone
City  State   Zip Code Work Phone    
Birth Date     SS#  Employer    
Insurance Company   Group # Subscriber ID#
Is patient covered by additional dental insurance? 
YesNo
  (If yes, please complete the following:)
Policy Holder Name    Relation to patient
Home Address Home Phone
City  State   Zip Code Work Phone    
Birth Date     SS#  Employer    
Insurance Company   Group # Subscriber ID#

 

INSURANCE AUTHORIZATION & FINANCIAL RESPONSIBILITY AGREEMENT

 

I understand that I am financially responsible for all charges whether or not paid by insurance.  I assign all insurance benefits directly to

the doctor otherwise payable to me for services rendered.  I hereby authorize the doctor to release all information necessary to secure the

payment of benefits.  I authorize the use of this signature on all insurance submissions.

I understand that I am financially responsible for all charges whether or not paid by insurance. Returned checks are subject to a $10.00 fee and balances older than 60 days may be subject to collection fees and finance charges at the rate of 1.5% per month (18% annually). Additionally, at the discretion of our practice we may charge you $25.00 for appointments that you do not keep and for appointments that you do not cancel with 24 hour notice. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

 

 

Signature (Parent/Guardian if under age 18)                Relationship (if patient is under age 18)                            Date       

 

Medical History                                                                     
Patient Name   

Physician’s Name                             Phone                                Date of Last Visit  

Please check the box if you have ever had any of the following :  
AIDS or HIV positiveAcid Reflux/ G.E.R.DArthritis, (Supply Type in Details Below)
Artificial jointsAsthmaCancer
Chemical DependencyDiabetes, (Supply Type in Details Below)Eating disorder
EpilepsyExcessive bleedingGlaucoma
Hepatitis, (Supply Type in Details Below)Kidney problemsLiver problems or Jaundice
Lung or breathing problemsSinus troubleSmoking/chewing tobacco
StrokeSwollen neck glandsThyroid problems
Tuberculosis

Heart Problems

Artificial valves
Congential heart defects
Heart Surgeries
High blood pressure
Infective (Bacterial) Endocarditis
Low blood pressure
Pacemaker
Other (Supply details below)

Give details of the above ‘Yes’ items
Antibiotics for dental treatment
Currently under a physician's care
Serious illnesses/hospitalizations
Women: ALLERGIES Please checkmark if you are allergic to:
Are you pregnant?
No
Yes

Due when?   
Are you nursing?  
No
Yes
Aspirin
Codeine
Latex
Local anesthetic
Penicillin
Sulfa

Other allergies:

MEDICATIONS: Please list medications you are currently taking and why:


Dental History (New Patients Only)

Checkmark if you have ever had any of the following:
Bad breath problemBiteguard / NightguardCanker sores in mouthCold sores on outer lips
Dental anesthetic problemsExcessive gag reflexFear of dental careFrequent headaches, neck aches
Full dentures / Partial denturesOral surgeryOrthodontics (braces)TMJ, jaw joint pain or treatment
Gum disease treatment

Checkmark if you currently have any of the following:
Bleeding gumsBroken tooth or fillingClenching or grinding of teethClicking or popping jaw
Dry mouthFood packing between teethLoose toothMouth breathing
PainSensitivity to - heat - cold - bitingSensitivity to - sweets - pressureSores or growths in mouth
SwellingTired, sore or painful jaw jointToothache Vague ache
Pain around ear

Other:
Give details and location of the above checked items:

 How often do you brush?                              floss?
What type toothbrush do you use?
Ultrsoft
Soft
Medium
Hard
Electric

Would you like improve the appearance of your smile?          How?   

Reason for today’s visit        

Former Dentist    City/State     Phone 

Date and reason of last dental visit                       Date of last dental X-rays

What have you liked about any dental office you’ve been to?     Least?


TREATMENT AUTHORIZATION

I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the

dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local

anesthetic and other medication as indicated.


Signature (Parent/Guardian if under age 18)
                Relationship (if patient is under age 18)                            Date       



Please enter code above in the field below.