New Patient Medical Forms

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Medical History — Part 1

Please answer YES or NO to each question. Your answers are for office records only and are strictly confidential.

General Health
1) Are you in good health?
2) Has there been any change in your general health within the past year?
4) Are you under the care of a physician?
6) Have you had any serious illness or operation?
7) Have you been hospitalized or had a serious illness within the past five years?
8) Do you have or have you had any of the following diseases or problems?
a) Damaged heart valves or artificial heart valves
b) Congenital heart lesions
c) Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke)
(1) Do you have pain in chest upon exertion?
(2) Are you ever short of breath after mild exercise?
(3) Do your ankles swell?
(4) Do you get short of breath when you lie down, or require extra pillows when you sleep?
(5) Do you have a cardiac pacemaker?
d) Allergy
e) Sinus Trouble
f) Asthma or hay fever
g) Hives or skin rash
h) Fainting spells or seizures
i) Diabetes
(1) Do you have to urinate (pass water) more than six times a day?
(2) Are you thirsty much of the time?
(3) Does your mouth frequently become dry?
j) Hepatitis, jaundice or liver disease
k) Arthritis
l) Inflammatory rheumatism (painful swollen joints)
m) Stomach Ulcers
n) Kidney trouble
o) Tuberculosis
p) Do you have a persistent cough or cough up blood?
q) Low blood pressure
r) Venereal disease
s) AIDS or HIV disease

Medical History — Part 2

Bleeding & Blood Disorders
9) Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?
a) Do you bruise easily?
b) Have you ever required a blood transfusion?
10) Do you have any blood disorder such as anemia?
11) Have you had surgery or x-ray for a tumor, growth, or other condition of your head or neck?
Current Medications
12) Are you taking any drug or medicine?

13) Are you taking any of the following?

a) Antibiotics or sulfa drugs?
b) Anticoagulants (blood thinners)?
c) Medicine for high blood pressure?
d) Cortisone (steroids)?
e) Tranquilizers?
f) Antihistamines?
g) Aspirin?
h) Insulin, tolbutamide (orinase) or similar drug?
i) Digitalis or drugs for heart trouble?
j) Nitroglycerin?
k) Oral contraceptives or other hormonal therapy?
l) Other medication not listed above?
Allergies & Adverse Reactions

14) Are you allergic or have you reacted adversely to any of the following?

a) Local anesthetics?
b) Penicillin or other antibiotics?
c) Sulfa drugs?
d) Barbiturates, sedatives, or sleeping pills?
e) Aspirin?
f) Iodine?
g) Codeine or other narcotics?
h) Other?
Dental & Additional Health History
15) Have you had any serious trouble associated with any previous dental treatment?
16) Do you have any disease, condition, or problem not listed above that you think we should know about?
17) Are you employed in a situation that exposes you regularly to x-rays or other ionizing radiation?
18) Are you wearing contact lenses?
19) Have you had any joint replacements: hip, knee, or shoulder?
20) Have you had any fusions of your neck or back?
21) Do you smoke?
For Women
22) Are you pregnant?
23) Do you have any problems associated with your menstrual cycle?
24) Are you nursing?
Chief Dental Complaint

Financial Policy Agreement

Dr. Bei Li — Financial Policy
861 Lafayette Rd., Unit 1, Hampton, NH 03842

Thank you for choosing our office for your dental needs. Dental treatment is an excellent investment in an individual's medical and psychological well being. Financial considerations should not be an obstacle to obtaining this important, life enhancing care. We are always available to answer your questions and/or assist you in any way we can.

Payment: All payment is due at the time treatment is rendered. We accept cash, checks, credit cards, and outside financing is available.

Dental Insurance: We are happy to assist you in filing the necessary forms to help you receive the full benefits of your coverage. The insurance relationship constitutes an agreement between the carrier and the patient. As such, we can make no guarantee of estimated coverage or payment. However, please know that we will do everything possible to see that you receive the full benefits of your policy.

Discount: We are happy to offer a 3% discount for all treatment over $2,000 that is paid in full prior to treatment.

Outstanding Accounts: An 18% annual percentage rate will be billed to outstanding accounts if not paid in full in the first 30 days.

Missed Appointments: If you do not show for an appointment or give proper 24-hour notice to cancel, you will be charged $75.00/hygiene and $150/doctor fees for the broken appointment.

I, [Your Name], understand that any insurance estimate given to me by this office is not a guarantee of actual insurance payment. I also understand that I am ultimately responsible for all charges incurred for dentistry performed upon myself or my dependents in this dental office. Any insurance claim not paid in full after 60 days will become my responsibility to pay at that time. I have read all of the above and agree to all terms.

HIPAA Notice of Privacy Practices

Dr. Bei Li, D.D.S.

* You May Refuse to Sign This Acknowledgment *

I have received a copy of this office’s Notice of Privacy Practices.

Our Notice of Privacy Practices describes how we may use and disclose your protected health information for treatment, payment, health care operations, and other purposes permitted or required by law. It also describes your rights to access and control your protected health information. You may refuse to sign this acknowledgment.

Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does not constitute legal advice. It covers only HIPAA, not other federal or state law. © 2010, 2013 American Dental Association. All Rights Reserved.

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