Health History & Privacy Practices

Secure, encrypted, HIPAA compliant form submission.
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Personal Information

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Marital Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Dental Benefits / Insurance Info

Do you have dental insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have secondary insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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2nd Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Emergency Contact

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Dental Questionnaire

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Do you floss regularly? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do your gums bleed while brushing or flossing? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are your teeth sensitive to hot, cold or sweets? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you chew/smoke tobacco in any form? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you had any head, neck or jaw injuries? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you notice popping, clicking or soreness of your jaw? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you clench or grind your teeth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever had orthodontic treatment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you wear dentures or partials? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you ever been told you have gum disease? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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MEDICAL INFORMATION

Each question defaults to NO.  Please read carefully. Select YES for all that apply.

ALLERGIES

Penicillin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Local Anesthetics {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Iodine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sulfa Drugs {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Asprin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Latex Rubber {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Erythromycin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Codeine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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CONDITIONS

Kidney Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Arthritis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Stroke {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Alcohol/Drug Abuse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Rheumatic Fever {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Heart Attack {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Congestive Heart Failure {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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HIV/AIDS Infection {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Blood Transfusion {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Blood Clotting Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Rheumatic Heart Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Heart Murmur {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Emphysema {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Angina/Chest Pain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Cardiac Pacemaker {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hives {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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CPAP User {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Diabetes {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Tuberculosis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Stomach Ulcers {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Anemia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Mitral Valve Prolapse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sleep Apnea {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bulimia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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High Blood Pressure {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fainting Spells {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Asthma {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Cancer/Tumor or Growth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bronchitis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Thyroid Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Frequent Headaches {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sinus Trouble {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lupus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Shortness of Breath {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Joint Replacement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Seizures {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Radiation/Chemo-therapy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Dry Mouth/Sjogren {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Gag Reflex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Cardiovascular/Heart Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you Pre-Medicate w/ Antibiotic {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hay Fever {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hepatitis: A, B or C {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sexually Transmitted Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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WOMEN

Are you pregnant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently nursing? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you on birth control pills? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PATIENT'S PHYSICIAN

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

CURRENT 

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

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

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

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

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

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ACKNOWLEDGEMENT OF PRIVACY PRACTICES 

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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 }
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LOCATION OF YOUR UPCOMING APPOINTMENT

To route infomation to the correct location.

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

By signing below, I certify that all of the above information is true to the best of my knowledge.

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Health History & Privacy Practices

The email has been sent.

Your progress has been saved.

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Health History & Privacy Practices

Secure, encrypted, HIPAA compliant form submission.
Completed or last updated on: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Personal Information

Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Middle Initial {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Nickname: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Birth Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Marital Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Zip Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Alternate Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Dental Benefits / Insurance Info

Do you have dental insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Carrier {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ID# {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Subscriber Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Subscriber Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Subscriber DOB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you have secondary insurance? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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2nd Insurance Carrier {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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2nd ID# {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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2nd Group Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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2nd Subscriber Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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2nd Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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2nd Subscriber Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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2nd Subscriber DOB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Emergency Contact

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

Current Dentist {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Last visit with your dentist (approximate) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Reason for today's visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you floss regularly? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do your gums bleed while brushing or flossing? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Are your teeth sensitive to hot, cold or sweets? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you chew/smoke tobacco in any form? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you had any head, neck or jaw injuries? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you notice popping, clicking or soreness of your jaw? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Do you clench or grind your teeth? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Have you ever had orthodontic treatment? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Do you wear dentures or partials? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Have you ever been told you have gum disease? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Any other dental issues? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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MEDICAL INFORMATION

ALLERGIES

Penicillin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Local Anesthetics {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Iodine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Sulfa Drugs {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Asprin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Latex Rubber {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Erythromycin {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Codeine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Other Allergies {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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CONDITIONS

Kidney Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Arthritis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Stroke {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Alcohol/Drug Abuse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Rheumatic Fever {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Heart Attack {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Congestive Heart Failure {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
HIV/AIDS Infection {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Blood Transfusion {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Blood Clotting Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Rheumatic Heart Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Heart Murmur {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Emphysema {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Angina/Chest Pain {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Cardiac Pacemaker {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Hives {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
CPAP User {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Diabetes {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Tuberculosis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Stomach Ulcers {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Anemia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Mitral Valve Prolapse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Sleep Apnea {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Bulimia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
High Blood Pressure {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fainting Spells {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Asthma {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Cancer/Tumor or Growth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Bronchitis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Thyroid Problems {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Frequent Headaches {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sinus Trouble {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lupus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Shortness of Breath {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Joint Replacement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Seizures {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Radiation/Chemo-therapy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Dry Mouth/Sjogren {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Gag Reflex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Cardiovascular/Heart Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Do you Pre-Medicate w/ Antibiotic {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hay Fever {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Hepatitis: A, B or C {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Sexually Transmitted Disease {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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WOMEN

Are you pregnant? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently nursing? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you on birth control pills? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PATIENT'S PHYSICIAN

Name of Family Physician {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are you currently under the care of your physician? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What condition is being treated? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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MEDICATIONS

CURRENT 

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

Have you taken bisphosphonates? Examples: Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia, Skelid, Reclast     {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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How long have you taken bisphoshonates? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Have you had bisphosphonate IV infusions? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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BLOOD THINNERS

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

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

Have you had any major recent surgeries? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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What type and when? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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PRIVACY PRACTICES

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ACKNOWLEDGEMENT OF PRIVACY PRACTICES 

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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 }
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LOCATION OF YOUR UPCOMING APPOINTMENT

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

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