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Health Questionnaire

Complete the Patient History form to submit the data electronically. Please fill out all items to the best of your knowledge.

    PATIENT INFORMATION

  • Do you have any dental work in progress at this time?YesNo
  • Patient's Sex:MaleFemale

  • Is Patient a Student?YesNo

  • What interests or hobbies does the patient enjoy?
  • If patient is a child, give parent or legal guardian name:
  • What would the patient/parent most like to accomplish with orthodontic treatment?

    SIBLINGS

    RESPONSIBLE PARTY

  • Marital Status:SingleMarriedSeparatedDivorcedWidowed

  • After reviewing the treatment plan, I authorize the release of any information related to this claim. I authorize payment of dental benefits directly to Montano Elevated Orthodontics.

    EMERGENCY INFORMATION

    HEALTH HISTORY

  • 1. Is the patient's health considered to be good?YesNo
  • 2. Is patient under medical treatment?YesNo
  • 3. Is patient currently taking any medication?YesNo
  • 4. Has patient ever taken medication for osteoporosis, such as Bisphosphonate. Boniva etc?YesNo
  • 5. Is patient allergic to any drugs or antibiotics, such as medication, Aspirin, Penicillin, etc?YesNo
  • 6. Has patient ever had an unfavorable reaction following dental treatment?YesNo
  • 7. Has patient had a cough for more than three weeks that is not explained by a non-infectious condition; exhibiting flu-like symptoms; or been diagnosed with H1N1?YesNo
  • 8. Female patients: Are you pregnant?YesNoN/A
  • 9. Does patient use tobacco?YesNo
  • 10. Has patient ever taken appetitie suppressants such as Fen-Phen (Fenfluramine and Phentermine), Dexfenfluramine Fenfluramine?YesNo
  • 11. Has patient been under the care of a medical doctor since taking any of the appetite suppressants named above?YesNo
  • 12. Does patient have or had any of the following conditions?
    AIDSArthritisAsthmaBleeding ProblemsCancerDiabetesEpilepsyHeart MurmurHeart ProblemsHepatitisHerpesHigh Blood PressureJaundiceKidney ProblemsLow Blood PressureRheumatic FeverStrokeTuberculosisVenereal Disease

    AUTHORIZATION

  • Patient Medical Dental History (ADULT) Health Insurance Portability and Accountability Act of 1996 (HIPAA).