PATIENT INFORMATION:
IN CASE OF EMERGENCY, WE SHOULD NOTIFY:
NAME* : MR.MISSMRS.MS.DR.
NAME* :
DATE OF BIRTH* :
RELATIONSHIP* :
ADDRESS (HOME)* :
DAY-TIME PHONE* :
NAME OF FAMILY DOCTOR* :
PHONE OR ADDRESS* :
PHONE* :
(1) NAME OF MEDICAL SPECIALIST :
ADDRESS (BUSINESS) :
AREA OF SPECIALITY :
PHONE OR ADDRESS :
PHONE :
(2) NAME OF MEDICAL SPECIALIST :
OCCUPATION :
WHO REFERRED YOU TO OUR OFFICE? :
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why? YESNONOT SURE / MAY BE
2. When was your last medical checkup?
3. Has there been any change in your general health in the past year? If yes, please explain. YESNONOT SURE / MAY BE
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list. YESNONOT SURE / MAY BE
5. Do you have any allergies? If you answered yes, please list using the following categories: medications, latex/rubber products, other (e.g. hayfever, foods) YESNONOT SURE / MAY BE
6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain. YESNONOT SURE / MAY BE
7. Do you have or have you ever had asthma? YESNONOT SURE / MAY BE
8. Do you have or have you ever had any heart or blood pressure problems? YESNONOT SURE / MAY BE
9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? YESNONOT SURE / MAY BE
10. Do you have a prosthetic or artificial joint? YESNONOT SURE / MAY BE
11. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? YESNONOT SURE / MAY BE
12. Have you ever had hepatitis, jaundice or liver disease? YESNONOT SURE / MAY BE
13. Do you have a bleeding problem or bleeding disorder? YESNONOT SURE / MAY BE
14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain. YESNONOT SURE / MAY BE
15. Do you have or have you ever had any of the following? Please check.chest pain, anginarheumatic feverpacemakersteroid therapyseizures (epilepsy)heart attackmitral valve prolapselung diseasediabeteskidney diseasestroketuberculosisstomach ulcersthyroid diseaseshortness of breathheart murmurcancerarthritisdrug/alcohol dependencyosteoporosis medications (e.g. Fosamax, Actonel)
16. Are there any conditions or diseases not listed above that you have or have had? If so, what? YESNONOT SURE / MAY BE
17. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease) YESNONOT SURE / MAY BE
18. Do you smoke or chew tobacco products? YESNONOT SURE / MAY BE
19. Are you nervous during dental treatment? YESNONOT SURE / MAY BE
20. For women only :Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date? YESNONOT SURE / MAY BE
