Health Questionnaire

Last Name*
First Name*
Middle Initial
Gender*
- Male
- Female
Birth Date*

MM slash DD slash YYYY
Have you ever had any of the following? Please check those that apply:
- AIDS
- Anemia
- Artificial Joint
- Blood Disease
- Cancer
- Chemical Dependency
- Chemotherapy
- Diabetes
- Epilepsy
- Fainting
- Glaucoma
- Head Injuries
- Heart Attack
- Heart Disease
- Heart Murmur
- Hepatitis
- High Blood Pressure
- Kidney Disease
- Mental Health Disorders
- Mitro Valve Prolapse
- Nervous Disorders
- Pacemaker
- Pregnancy Due
- Respiratory Problem
- Rheumatic Fever
- Rheumatism
- Sinus Problems
- Stroke
- Tuberculosis
- Tumors
- Ulcers
- Codeine Allergy
- Erythromycin Allergy
- Penicillin Allergy
- Sulfa Allergy
What type of cancer and when where you diagnosed?
When was your heart attack?
When did you get your pacemaker?
When is your pregnancy due?
Tell us more about your tumors.
Please list current medications you take:
Have you ever had any complications following dental treatment?
Primary physician
Payments*
- I understand that all services furnished are charged directly to me and I am responsible for payment. If I carry dental insurance, I understand Kappenman Dental will submit claims and credit any payments to my account. I hereby authorize Kappenman Dental Clinic to administer medications and perform diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page is true and correct to the best of my knowledge. If I have any change in my health, I will inform the doctors at my next appointment.
Signature*
Date*

MM slash DD slash YYYY
Consent/Acknowledgement

By signing this revised form as of 09/23/2013, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices

You have the right to read our Notice of Privacy Practices before you decide to sign
the Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices.

If we change our privacy practices, we will issue a revised Notice of Privacy Practices. You may obtain a copy at any time by contacting:
Dawn Jorgensen (605) 361-9288, 5704 W. 41st Street Sioux Falls, SD 57106
Protected Health Information for Treatment*
- I have had the opportunity to read the consent form. I understand by signing this Consent that I am giving my consent to your use and disclosure of my protected health information for treatment, payment activities health care operations.
- I revoke my Consent for your use and disclosure of my protected health information for treatment, payment and healthcare operations.
Consent Signature*
Revoke Signature*
Date*

MM slash DD slash YYYY

Health Questionnaire

Have you ever had any of the following? Please check those that apply:

Consent/Acknowledgement

Notice of Privacy Practices