Health History & Privacy Practices

Secure, encrypted, HIPAA compliant form submission.

Completed or last updated on: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Personal Information

Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Middle Initial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Nickname: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Birth Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Marital Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Zip Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Alternate Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dental Benefits / Insurance Info

Do you have dental insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Carrier {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ID# {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Subscriber Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Subscriber Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Subscriber DOB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have secondary insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

2nd Insurance Carrier {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

2nd ID# {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

2nd Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

2nd Subscriber Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

2nd Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

2nd Subscriber Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

2nd Subscriber DOB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Emergency Contact

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Relationship to patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dental Questionnaire

Current Dentist {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last visit with your dentist (approximate) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Reason for today's visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you floss regularly? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do your gums bleed while brushing or flossing? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are your teeth sensitive to hot, cold or sweets? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you chew/smoke tobacco in any form? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had any head, neck or jaw injuries? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you notice popping, clicking or soreness of your jaw? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you clench or grind your teeth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you ever had orthodontic treatment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you wear dentures or partials? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you ever been told you have gum disease? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Any other dental issues? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

MEDICAL INFORMATION

ALLERGIES

Penicillin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Local Anesthetics {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Iodine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sulfa Drugs {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Asprin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Latex Rubber {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Erythromycin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Codeine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other Allergies {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CONDITIONS

Kidney Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Arthritis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Stroke {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Alcohol/Drug Abuse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Rheumatic Fever {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Heart Attack {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Congestive Heart Failure {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

HIV/AIDS Infection {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Blood Transfusion {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Blood Clotting Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Rheumatic Heart Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Heart Murmur {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Emphysema {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Angina/Chest Pain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cardiac Pacemaker {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Hives {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CPAP User {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Diabetes {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Tuberculosis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Stomach Ulcers {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Anemia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mitral Valve Prolapse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sleep Apnea {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Bulimia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

High Blood Pressure {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Fainting Spells {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Asthma {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cancer/Tumor or Growth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Bronchitis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Thyroid Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Frequent Headaches {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sinus Trouble {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lupus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Shortness of Breath {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Joint Replacement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Seizures {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Radiation/Chemo-therapy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dry Mouth/Sjogren {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Gag Reflex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cardiovascular/Heart Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you Pre-Medicate w/ Antibiotic {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Hay Fever {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Hepatitis: A, B or C {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Sexually Transmitted Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had any serious illnesses, operations, been hospitalized in the last 5 years or any other medical issues or concerns not listed above? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

WOMEN

Are you pregnant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you currently nursing? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you on birth control pills? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

PATIENT'S PHYSICIAN

Name of Family Physician {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you currently under the care of your physician? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What condition is being treated? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

MEDICATIONS

CURRENT

Do you currently take any medications? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please either list your medications or upload a file containing the information. Which do you prefer? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please list medications {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please upload file {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

BISPHOSPHONATES

Have you taken bisphosphonates? Examples: Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia, Skelid, Reclast {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

How long have you taken bisphoshonates? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you had bisphosphonate IV infusions? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

BLOOD THINNERS

Are you taking blood thinners? Examples: Xarelto, Warfarin (Coumadin, Jantoven), Enoxaparin (Lovenox), Heparin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

IMMUNOSUPPRESSANTS

Are you taking immunosuppressants? Examples: adalimumab (Humira), etanercept (Enbrel), prednisone (Deltasone, Orasone) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

SURGERY

Have you had any major recent surgeries? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What type and when? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

PRIVACY PRACTICES

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the person(s) indicated below. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

LOCATION OF YOUR UPCOMING APPOINTMENT

Choices: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

SIGNATURE

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Signature of parent or guardian {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Parent or guardian's name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Health History & Privacy Practices

Personal Information

Dental Benefits / Insurance Info

Emergency Contact

Dental Questionnaire

MEDICAL INFORMATION

ALLERGIES

CONDITIONS

WOMEN

PATIENT'S PHYSICIAN

MEDICATIONS

CURRENT

BISPHOSPHONATES

BLOOD THINNERS

IMMUNOSUPPRESSANTS

SURGERY

PRIVACY PRACTICES

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

ADDITIONAL DISCLOSURE AUTHORITY

LOCATION OF YOUR UPCOMING APPOINTMENT

SIGNATURE

Health History & Privacy Practices

Your progress has been saved.

Health History & Privacy Practices

Personal Information

Dental Benefits / Insurance Info

Emergency Contact

Dental Questionnaire

MEDICAL INFORMATION

ALLERGIES

CONDITIONS

WOMEN

PATIENT'S PHYSICIAN

MEDICATIONS

CURRENT

BISPHOSPHONATES

BLOOD THINNERS

IMMUNOSUPPRESSANTS

SURGERY

PRIVACY PRACTICES

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

ADDITIONAL DISCLOSURE AUTHORITY

LOCATION OF YOUR UPCOMING APPOINTMENT

SIGNATURE