PATIENT HISTORY FORM, continued

ALLERGIES

REFERRALS

IN CASE OF EMERGENCY

NOTICE OF PRIVACY PRACTICES

Have you ever had any of the following diseases or medical problems?

Heart Attack

Prosthesis

Details

Aspirin

Antibiotics

Pain Pills

Dental Anesthetics

Latex

Tetracycline

Penicillin

Other

Cancer

Diabetes

Rheumatic fever

HIV+AIDS

Hemophilia

Asthma

Hepatitis

Tuberculosis

Shingles

Fever blisters

Venereal disease

Ulcers/colitis

Heart murmur

Emphysema

Sinus problems

Scarlet fever

Sev./Freq. Headaches

High/low bloodPressureDrug/alcohol abuse

Blood transfusion

Anemia/radiation

Glaucoma

Breathing dif�culty

Other

Congenital HeartDefectConvulsions/EpilepsyAbnormal bleeding

Arti�cial valves

Heart surgery/PacemakerHospital stays otherThan for pregnancyKidney/liverProblems

Mitrial valveProlapseArti�cial bones/Joints

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

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Yes No

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Yes No

We are dedicated to protecting your personal medical information and following all provisions required by law. You are entitles to reviewOur complete Privacy Notice which describes how we may use and disclose your medical records while you are receiving care at ImagineOrthodontics. A laminated copy of our Notice of Privacy Practices is maintained at the reception desk and is available To you for review or to obtain a photo copy

Whom may we thank for referring you?

I understand the information that i have given is correct to the best of my knowledge and it is my responsibility to inform this of�ce of anyChanges in my medical status.

Name of local friend or relative (not living at the same address)

Relationship to patient

Phone # ( )Name

Doctor Doctor Radio Newspaper Staff Television Yellow PagesOther

Yes No

16920 Wright Plaza Suite 106 Omaha, NE 68130Phone: (402) 778-5800 Fax: (402) 778-5805

10701 South 72nd Street Suite 106 Omaha, NE 68046Phone: (402) 597-6100 Fax: (402) 597-6101

Signature of Patient/Legal Guardian Date

Doctor’s Signature Date

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

PATIENT HISTORY FORMPATIENT INFORMATION

RESPONSIBLE PARTY

INSURANCE INFORMATION(Please give your insurance card to the receptionist)

Today’s Date:

What would you like to change about your smile?

Do you have any pain now?

Have you ever had any serious/dif�cult problemAssociated with previous dental work?

Physician Name

Are you Pregnant?

Are you currently under a doctor's care if yes, why? Are you taking any prescription drugs?

Physician Phone Date of last visit

Do your gums bleed?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes NoHave you ever had any pain or tenderness in the jaw joint(TMJ/TMD)? Yes No

Insurance Company Name

Secondary Insurance Company Name (if Applicable)

Address

Contact City State ZIP

How long have you worked there

Insured’s Name

Patient’s relationship to insured

Employer Address

Self Spouse Child Other

Patient’s relationship to insuredSelf Spouse Child Other

Patient’s Last Name

Preferred name or Nickname

School/Occupation

Home Address City

DOB / / - -

State ZIP Code

GenderSSN

Email Address

First Middle

F M

16920 Wright Plaza Suite 106 Omaha, NE 68130Phone: (402) 778-5800 Fax: (402) 778-5805

10701 South 72nd Street Suite 106 Omaha, NE 68046Phone: (402) 597-6100 Fax: (402) 597-6101

Responsible Last Name

Home Address

Email Address

When is the best time to reach you?

Home Phone ( )

Employer Phone Employer Occupation( )

Phone ( )

Cell Phone ( )

Work Phone ( )

State

First

City

Middle Relationship to Patient

DOB / /

DOB

Group Name

/ /

- -SSN

- -Insured’s SSN

Group ID #

Home Cell LunchWork a.m. p.m.

DENTIST INFORMATION

Dentist Name

Home Address

Phone ( )

Fax( )

State ZIP CodeCity

DENTAL/MEDICAL HISTORY

( )