Patient Registration and Health History · 2019. 12. 27. · Did you ever have braces, orthodontic treatment or had your bite adjusted, ... information. Please review it carefully.

Patient Registration and Health History

Patient Information – Tell us about yourself

First Name: Last Name: Middle Initial: Preferred Name:_______________________ ___________________________ ____ _______________

Address: ____________________________________________ City: ______________________________ State: ___________ Zip: _________

Cell Phone: _________________________ Work Phone: _________________________ Home Phone: ____________________ Text Msg: Y / N

Sex (select): Male Female Marital Status (select): Married Single Divorced Separated Widowed

Birth Date: ___________________ Social Security #: _____________________________ Driver’s License: ____________________________

Email:______________________________________________ I would like to receive email appointment reminders & correspondence: Y / N

Employment Status (select one): Full Time Part Time Retired Other Employer: __________________________________________

Student Status (select one): Full Time Part Time Name of School/College__________________________________________________

How did you hear about Atlantic Dental Group: ___________________________________________________________________________________

Insurance Information – Let us know if we will be filing insurance on your behalf

Primary Dental Insurance Co:____________________________________ Group #: ______________________ ID #: ______________________

Insurance Co Address: Insurance Co Phone:___________________________________________________ ________________________________

Name of Insured: ______________________________________________ Relationship to Insured (select): Self Spouse Child Other

Insured Social Security #: __________________________ Insured Birth Date: _________________ Employer ______________________________

Secondary Dental Insurance Co:__________________________________ Group #: _____________________ ID #: _____________________

Insurance Co Address: Insurance Co Phone:____________________________________________________ ______________________________

Name of Insured: ______________________________________________ Relationship to Insured (select): Self Spouse Child Other

Insured Social Security #: __________________________ Insured Birth Date: _________________ Employer ______________________________

Account Information / Responsible Party – Who is responsible for any account balance?

First Name: _____________________________________ Last Name: _________________________________ Middle Initial: _______

Address: ______________________________________________ City: ______________________________ State: ___________Zip: __________

Home Phone: ___________________________ Work Phone: ___________________________ Cell: ________________________

Birth Date: __________________________ Social Security #: ____________________ Driver’s License: ____________________

In the Event of An Emergency – Whom should we contact?

Name: _______________________________________ Relationship to Patient: _____________________ Phone: ________________________

Page 1 of 4

Name______________________________ Nickname_____________________________ Age_________Referred by__________________________How would you rate the condition of your mouth? Excellent Good Fair PoorPrevious Dentist ______________________________How long have you been a patient?___________Months/YearsDate of most recent dental exam ______/______/______ Date of most recent x-rays ______/______/______ Date of most recent treatment (other than a cleaning) ______/______/______I routinely see my dentist every: 3 mo. 4 mo. 6 mo. 12 mo. Not routinely

WHAT IS YOUR IMMEDIATE CONCERN? _____________________________________________________________________________

1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) [____]__________________________________2. Have you had an unfavorable dental experience?___________________________________________________________________3. Have you ever had complications from past dental treatment?_________________________________________________________4. Have you ever had trouble getting numb or had any reactions to local anesthetic?__________________________________________5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?________________________________6. Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?_______________

7. Do your gums bleed or are they painful when brushing or flossing? _____________________________________________________8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? _____________________________9. Have you ever noticed an unpleasant taste or odor in your mouth? _ ____________________________________________________10. Is there anyone with a history of periodontal disease in your family? _____________________________________________________11. Have you ever experienced gum recession? _______________________________________________________________________12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? _____________13. Have you experienced a burning or painful sensation in your mouth not related to your teeth? ________________________________

14. Have you had any cavities within the past 3 years? ___________________________________________________________________15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? _________________________16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? ______________________________________17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?___________________________18. Do you have grooves or notches on your teeth near the gum line? ______________________________________________________19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? __________________________________________20. Do you frequently get food caught between any teeth? _______________________________________________________________

21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) _________________________________22. Do you feel like your lower jaw is being pushed back when you bite your back teeth together?________________________________23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? ______________24. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?_______________________25. Are your teeth becoming more crooked, crowded, or overlapped? _____________________________________________________26. Are your teeth developing spaces or becoming more loose? __________________________________________________________27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?__28. Do you place your tongue between your teeth or close your teeth against your tongue?_____________________________________29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? ________________________________30. Do you clench or grind your teeth together in the daytime or make them sore?____________________________________________31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?___32. Do you wear or have you ever worn a bite appliance? ________________________________________________________________

33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?_________________________34. Have you ever whitened (bleached) your teeth? ____________________________________________________________________35. Have you felt uncomfortable or self conscious about the appearance of your teeth? ________________________________________36. Have you been disappointed with the appearance of previous dental work? ______________________________________________Patient’s Signature ________________________________________________________________________________Date _______________________Doctor’s Signature __________________________________________________________________________________ Date _______________________

GUM AND BONE

BITE AND JAW JOINT

SMILE CHARACTERISTICS

To order, please visit: www.koiscenter.com

DENTAL HISTORY

PERSONAL HISTORY

TOOTH STRUCTURE

PLEASE ANSWER YES OR NO TO THE FOLLOWING: YES NO

© 2016 Kois Center, LLC

www.koiscenter.com © 2018 Kois Center, LLC

MEDICAL HISTORYPatient Name Nickname Age Name of Physician/and their specialty Most recent physical examination Purpose What is your estimate of your general health? Excellent Good Fair Poor

DO YOU HAVE or HAVE YOU EVER HAD: YES NO YES NO1. hospitalization for illness or injury 2. an allergic or bad reaction to any of the following:

aspirin, ibuprofen, acetaminophen, codeinepenicillinerythromycintetracyclinesulfalocal anestheticfluoridechlorhexidine (CHX)metals (nickel, gold, silver, )latex nuts fruit other

3. heart problems, or cardiac stent within the last six months 4. history of infective endocarditis 5. artificial heart valve, repaired heart defect (PFO) 6. pacemaker or implantable defibrillator 7. orthopedic implant (joint replacement) 8. rheumatic or scarlet fever 9. high or low blood pressure 10. a stroke (taking blood thinners) 11. anemia or other blood disorder 12. prolonged bleeding due to a slight cut (INR > 3.5) 13. pneumonia, emphysema, shortness of breath, sarcoidosis 14. chronic ear infections, tuberculosis, measles, chicken pox 15. asthma 16. breathing or sleep problems (e.g., sleep apnea, snoring, sinus) 17. kidney disease 18. liver disease 19. jaundice 20. thyroid, parathyroid disease, or calcium deficiency 21. hormone deficiency 22. high cholesterol or taking statin drugs 23. diabetes (HbA1c = ) 24. stomach or duodenal ulcer 25. digestive or eating disorders (e.g., celiac disease, gastric reflux,

bulimia, anorexia)

26. osteoporosis/osteopenia (e.g., taking bisphosphonates) 27. arthritis 28. autoimmune disease

(e.g., rheumatoid arthritis, lupus, scleroderma) 29. glaucoma 30. contact lenses 31. head or neck injuries 32. epilepsy, convulsions (seizures) 33. neurologic disorders (ADD/ADHD, prion disease) 34. viral infections and cold sores 35. any lumps or swelling in the mouth 36. hives, skin rash, hay fever 37. STI/STD/HPV 38. hepatitis (type ) 39. HIV/AIDS 40. tumor, abnormal growth 41. radiation therapy 42. chemotherapy, immunosuppressive medication 43. emotional difficulties 44. psychiatric treatment 45. antidepressant medication 46. alcohol/recreational drug use

ARE YOU:47. presently being treated for any other illness 48. aware of a change in your health in the last 24 hours

(e.g., fever, chills, new cough, or diarrhea) 49. taking medication for weight management 50. taking dietary supplements 51. often exhausted or fatigued 52. experiencing frequent headaches 53. a smoker, smoked previously or use smokeless tobacco 54. considered a touchy/sensitive person 55. often unhappy or depressed 56. taking birth control pills 57. currently pregnant 58. diagnosed with a prostate disorder

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List all medications, supplements, and or vitamins taken within the last two yearsDrug Purpose Drug Purpose

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Patient’s Signature

Doctor’s Signature

Date

Date

ASA (1-6)

Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed, and how you can gain 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 1/1/03 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 the changes in our privacy practices and the new terms of our Notice effective for all health in formation 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, of 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 dentist, physician, or other healthcare provider providing treatment to you.

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

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating 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 us written authorization to use your health information or to disclose it to anyone for any 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 Family and Friends: 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 you 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, your general condition or death. If you are present, then prior to use or disclosure of your health information, we will provide you with 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 bet interest allowing a person to pick up filled prescriptions, health 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 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 a 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 safety or the health or 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 officials 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 appointment reminders (such as voicemail, e-mail or text 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 may charge you a reasonable cost-based fee for expenses such as copies, postage and staff time. If you request an alternative format, we may charge a cost-based free for providing your health information in that format. If you prefer, we may – but are not required to – 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 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable cost-based fee for responding to these additional requests.

Restriction: 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). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. Your request is not binding unless our agreement is in writing.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location, 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 your request under certain circumstances.

Electronic Notice: If you receive this Notice on a website 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 access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may 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 your 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.

Privacy Officer: Practice Manager / HIPPA Compliance Officer Telephone: 910-762-0958 Fax: 910-762-2771 Address: 1301 Physicians Drive, Wilmington, NC 28401

HIPAA Privacy Permission Form By signing this form, I give Atlantic Dental Group permission to disclose my Protected Health Information (PHI) to the individuals listed below. The PHI that Atlantic Dental Group may disclose is limited to information directly related to that person’s involvement in my health care or payment of my health care.

Name Phone Number Relationship to Patient

_________________________________________________________________________________________________ PATIENT Name (please print) Social Security # Date of Birth _________________________________________________________________________________________________ PARENT / GUARDIAN Name (please print) _________________________________________________________________________________________________ Mailing Address City, State, Zip _________________________________________________________________________________________________ Patient’s or Guardian’s Signature Date

*******************************************************************************************************************

Acknowledgement of Receipt of Notice of Privacy Practices You may refuse to sign this acknowledgement. I, ___________________________________, acknowledge that I have received a Notice of Privacy Practices from

Atlantic Dental Group. ______________________________________________________________________________________________ Signature Date If personal representative signs this authorization on behalf of the individual, please complete the following: Personal Representative’s Name (please print): __________________________________________________________ Relationship to Individual (please print): __________________________________________________________

For Office Use Only We attempted to obtain written acknowledgment of our Notice of Privacy Practices, as required by law, but acknowledgment could not be obtained because: _____ Individual refused to sign _____ Communication barriers prohibiting obtaining the acknowledgment _____ An emergency situation prevented us from obtaining acknowledgment _____ Other (please specify): _________________________________________________________________

Appointments and Cancellation Policy

We understand that personal schedules may get interrupted, so we ask that you contact us as soon as possible if you are unable to keep your appointment. However, because we reserve time especially for you, broken appointments negatively impact both our schedule and the care for other patients. Therefore, we require 2 business days notice of cancellation. Please note: Monday appointments must be cancelled by Thursday to avoid a potential fee. Cancellations may be made by emailing [email protected] or by calling (910) 762-0958. Cancellations cannot be made through text.

A Cancellation fee may be charged in any of the following scenarios:

• No show for an appointment without any notice to the office

• Cancellation or broken appointment with less than 2 business days’ notice

Cancellation fees are $25 for hygiene appointments and $50 for doctor treatment appointments.

Please note, patients who miss more than 2 appointments within an 18-month period may be required to pre-pay for any future appointments. Patients with a history of multiple cancelled or broken appointments may result in dismissal from our practice.

Returned Checks

There will be a $25 fee for returned checks.

Past Due Finance Charges and Penalties

Monthly finance charges of 1.5% (minimum fee is $1) will be added to accounts which are over 60 days past due. *************************************************************************************************************************************** Thank you for understanding our financial and insurance policies. If you have any questions do not hesitate to ask us as we are here to assist you.

Patient Name (please print)

Patient Signature Date

Yes No

Are you comfortable showing your teeth when you smile?

Are you happy with the appearance of your teeth?

Do you have unsightly crowns or fillings?

Are your gums or teeth sensitive?

Do you feel your teeth are too long or too short?

Do you like the color of your teeth?

Are you interested in replacing any missing teeth?

Are you interested in improving the appearance of your teeth?

Are you familiar with the benefits of dental implants?

Are your gums receding?

Do your teeth come together in an acceptable manner?

SMILE ASSESSMENTand see if you might be a candidate for an enhanced smile.

Take our…

What is holding you back from your perfect smile?

Fear

Time

Cost

Other: ______________________________________________________________

1301 Physicians Drive • Wilmington, NC 28401• P: 910-762-0958 • atlantic-dental.com

Please feel free to explain any answers.

_____________________________________________________________________

_____________________________________________________________________

© 2009 Watermark Medical

Watermark Medical ARES Questionnaire

PRINT IN CAPITAL LETTERS – STAY WITHIN THE BOX

COMPLETELY FILL IN ONE CIRCLE FOR EACH QUESTION – ANSWER ALL QUESTIONS

Have you been diagnosed or treated for any of the following conditions?

NoYesStrokeNoYesHigh blood pressure

Heart disease Yes No Depression Yes No

NoYesSleep apneaNoYesDiabetes

Lung disease Yes No Nasal oxygen use Yes No

NoYesRestless leg syndromeNoYesInsomnia

Narcolepsy Yes No Morning Headaches Yes No

Pain MedicationNoYesSleeping Medication e.g., vicodin, oxycontin NoYes

Signature Area Code Phone Number Total all 6 boxes from above Point Total

If point total = 4 or 5 (low risk), 6 to 10

(high) and 11 or more (very high risk)

First Name Middle Initial Last Name

Pounds Years Gender

Weight

Age

Male Female

Feet Inches Inches

Height

Neck Size

Month Day Year Optional

Date of Birth

ID Number

Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to mark the most appropriate box for each situation. (M.W. Johns, Sleep 1991)

1 = slight chance of dozing0 = would never doze

3 = high chance of dozing2 = moderate chance of dozing 3210

Sitting and reading

Watching TV

Sitting, inactive, in a public place (theater, meeting, etc)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch without alcohol

In a car, while stopped for a few minutes in traffic

1 - 2 ti0 - 1 times/weekFrequency 5 - 7 times/week3 - 4 times/weekmes/week

On average in the past month, how often have you snored or been told that you snored?

Almost alwaysFrequentlySometimesRarelyNever

Do you wake up choking or gasping?

RarelyNever Sometimes Frequently Almost always

Have you been told that you stop breathing in your sleep or wake up choking or gasping?

RarelyNever Sometimes Frequently Almost always

Do you have problems keeping your legs still at night or need to move them to feel comfortable?

RarelyNever Sometimes Frequently Almost always

Tally ARES Risk Points

Neck Size +2 Male >16.5 +2 Female>15.0

Co-morbidities +1 for each Yes

response

Assign points for each of the first three responses

Epworth Score TOTAL the

values from all 8 questions, If 11 or less Score = 0

If 12 or more Score = 2

+1

+1

+1

+2

+2

+2

+3

+3

+3

+4

+4

+4

Do not assign any points for

these eight responses

Score

Score

Score

Request for Records to Be Released To: Atlantic Dental Group 1301 Physicians Drive Wilmington, NC 28401 Phone: 910-762-0958 Fax: 910-762-2771 To Whom It May Concern: I hereby authorize the release of any dental records and x-rays to the office of Dr. Frazelle, Dr. Lee and Dr. Winneberger of Atlantic Dental Group. Name of Prior Dentist: ______________________________________________________________________________ Address: ________________________________________________________________________________________ Phone Number: ___________________________________ Fax Number: _________________________________ Email: __________________________________________________________________________________________ Patient Name (Please Print): _________________________________________________________________________ Patient Date of Birth: _______________________________________________________________________________ _________________________________________________________________________________________________ Patient / Guardian Signature Date Please Note: Email is the preferred method of receiving x-rays. Please send the images in Dexis format (.dex) or JPEG (.jpg) to: [email protected] or mail them to the address noted above. Please include the date the x-rays were taken. Thank you.