Welcome to our Practice! Please help us by providing the following confidential information.
PATIENT INFORMATION Name (last, first, middle):_____________________________________________Preferred________________ Date of Birth_________________ Sex : M_______ F_______ SS#_________________________________ Drivers License #:_____________________ Email address_________________________________________ Home Address:______________________________________ City______________ State____ Zip________
Home Phone_____________________, Work______________________ Cell__________________________ Occupation__________________________ How did you hear about our office?_________________________ Emergency Contact Name ___________________________________ Phone #________________________ Primary Dental Insurance Information Policy Holder Name____________________________________ Relationship to Patient_________________ Employer_______________________________ Phone #__________________________________________ Birth date_______________ SS# or SID_________________________ Group #_______________________ Insurance Company_____________________________Address_____________________________________ City________________ State______________ Zip____________ Phone #____________________________ Secondary Dental Insurance (if applicable) Policy Holder Name____________________________________ Relationship to Patient_________________ Employer_______________________________ Phone #__________________________________________ Birth date_______________ SS# or SID_________________________ Group #_______________________ Insurance Company_____________________________Address_____________________________________ City________________ State______________ Zip____________ Phone #____________________________ I hereby authorize the release of any information to my insurance company or companies, including records of examinations, diagnosis and/or treatment. This release is solely for the purpose of facilitating the billing and reimbursement, directly to Dr. Schillinger of insurance benefits under which I am entitled. I hereby agree that I am financially responsible for all treatment rendered, and understand that complete payment will be made after each treatment, unless other financial arrangements have been previously arranged. Patient’s Signature _____________________________ Date_______________________________________ Notice of Privacy Practices Acknowledgement
I understand that, under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be
involved with that treatment directly and indirectly.
Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physicians certifications.
I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Patient Name:
Relationship to Patient: _____________________________________________ Signature:
Patient Authorization for Use and Disclosure of Protected Health Information
By signing, I authorize Deer Run Dental to use and/or disclose certain protected health information (PHI) about me to carry out treatment, payment activities, and healthcare operations. This authorization permits Deer Run Dental to use and/or disclose the following individually identifiable health information about me: All information in regards to dental care
Along with Deer Run Dental information may be shared with: __________________________________________ ____________________________________ Print Name Relationship to patient __________________________________________ ____________________________________ Print Name Relationship to patient I do not have to sign this authorization in order to receive treatment from Deer Run Dental. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Office Manager at Deer Run Dental, 2127 Lebanon Ave., Shiloh, IL 62221 ____________________________ _____________________ __________________ Signature Relationship to patient Date Office use only
I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as stated below: Date: __________________
MEDICAL HEALTH HISTORY PATIENT NAME: ________________________ A. CIRCLE YOUR ANSWERS (leave BLANK if you do not understand the question): 1. Yes No Are you in good health? 2. Yes No Has there been a change in your health within the last year? Explain: _______________________________________________ 3. Yes No Have you been hospitalized or had a serious illness in the last 5 years? Explain:______________________________________ ___________________________________________________________________________________________________________________ 4. Yes No Are you being treated by a physician now? Explain: ___________________________________________________________ Name of your physician: __________________________________________ Date of last Medical Exam: _____________________________ B. CHECK THE FOLLOWING IF YOU HAVE OR HAVE HAD SERIOUS PROBLEMS WITH: 5. ________ Chest Pains
8. ________ Recent weight loss, fever, night sweats
9. ________ Persistent cough, coughing up blood
10. ________ Bleeding problems, bruising easily
13. ________ Diarrhea, constipation, blood in stools
15. ________ Difficulty urinating, blood in urine
27. ________ Sleep apnea or chronic snoring
C. CHECK THE FOLLOWING IF YOU HAVE OR HAVE HAD:
29. ________ Heart attack, heart defects
32. ________ Stroke, hardening of arteries
34. ________ TB, emphysema or other lung diseases
45. ________ STD (syphilis or gonorrhea)
38. ________ Family History of diabetes, heart problems, cancer
D. CHECK THE FOLLOWING IF YOU HAVE OR HAVE HAD: 49. ________ Surgeries ___________________________________
50. ________ Blood Transfusions __________________________
51. ________ Artificial Joint _______________________________
52. ________ Contact Lenses ______________________________
53. ________ Psychiatric Care _____________________________
58. ________ Women only: Birth Control Pills
59. ________ Women only: Presently pregnant or nursing
E. DO YOU TAKE OR HAVE TAKEN: VITAMINS & MEDICATIONS: ___________________
62. ________ Tobacco in any forms 63. ________ Phen Phen diet pills or any other diet pills
F. ALLERGIES: (Drugs, food, medication, metals, jewelry, acrylics, etc.):___________________________________________________ _________________________________________________________________________________________________________________
G. ALL PATIENTS: 65. Yes No Do you have or have you had any other diseases or medical problems NOT listed on this form? If so, please explain: _____________________________________________________________________________________________________________________ 66. Yes No Have you ever been told by a physician or dentist that you need to pre-medicate prior to any dental treatment? If so, please explain:______________________________________________________________________________________________________________
DENTAL HEALTH HISTORY
67. Name of your former dentist: ___________________________________________ How long since you were last seen? ____________
68. CIRCLE IF APPLICABLE:
Bleeding gums Sensitivity to hot and/or cold
Bad breath or sour taste in mouth Snoring
Burning sensations in mouth Food catching between teeth
Is it hard for you to open wide? Pain/soreness around ears, eyes, face
Clicking or popping in jaw Stiff neck muscles
Have your parents suffered from gum disease? Did your parents wear dentures/partials?
Ever been injured in your mouth or head?
69. Does having dental treatment make you afraid or nervous? [Y] [N] If yes, what specific things bother you? __________________
Which of the following are important to you when making your dental health decision?
My mouth is a) very comfortable b) moderately comfortable c) uncomfortable.
I am a) happy with the appearance of my mouth b) dissatisfied with the appearance of my mouth.
I a) will do anything to keep my natural teeth b) want to keep my teeth, but have a certain budget of time and
money that I am willing to spend on them.
I a) have set goals for my oral health with a previous dentist b) want to set goals concerning my dental health.
I a) have always done the best that was recommended for my dental health b) have not always done what dentists
have recommended to me c) rarely go and don’t care much about having any dental work completed.
I a) have put dentistry for myself and family high on my priority list b) put dentistry for myself and family low on
my priority list c) have dentistry on my list, but it is hard to find.
I think my present state of dental health is a) excellent b) good c) poor.
Many thanks to Julia Ross, the author of The Diet Cure , for her permission to place this questionnaire on the Total Fitness website. My goal in The Diet Cure is to stop your food cravings, address your eating and weight problems, and eliminate your mood swings and negative obsessions about your body. But first we have to determine what is causing these problems. Here is a mini-questionnai
What does hormone imbalance mean and how can it affect me? Pre-menstrual syndrome (PMS), irregular menses, infertility, fibrocystic breasts, uterine fibroids and menopause are representative of women’s health conditions that are caused by an imbalance in hormones. Causes can include exogenous estrogens; chemicals found in food, air and water; malfunctions in liver detox pathways and stres