Patient's medical history

PATIENT'S MEDICAL HISTORY PATIENTS NAME_____________________________________ DATE OF BIRTH_________________ ALTHOUGH DENTAL PERSONNEL PRIMARILY TREAT THE AREA IN AND AROUND YOUR MOUTH, YOUR MOUTH IS A PART OF YOUR ENTIRE BODY, HEALTH PROBLEMS THAT YOU MAY HAVE, OR MEDICATION THAT YOU MAY BE TAKING, COULD HAVE AN IMPORTANT INTERRELATIONSHIP WITH THE DENTISTRY THAT YOU WILL BE RECEIVING. THANK YOU FOR ANSWERING THE FOLLOWING QUESTIONS. ACTONEL OR ANY CANCER MEDICATIONS CONTAINING BISPHOSHONATES? HAVE YOU TAKEN VIAGRA, REVATIO, CIALIS OR ARE YOU NOW UNDER THE CARE OF A PHYSICIAN SURGICAL OPERATION OR SERIOUS ILLNESS. PLEASE EXPLAIN: INCLUDING NON-PRESCRIPTION MEDICINE. IF YES, KNOWN ILLNESS (LASTING MORE THAN 3 WEEKS). PROBLEM NOT LISTED ABOVE THAT YOU THINK I SHOULD KNOW ABOUT HAVE YOU EVER REQUIRED A BLOOD TRANSFUSION ARE YOU PREGNANT OR THINK YOU ARE PREGNANT ARE YOU ALLERGIC TO OR HAVE YOU HAD REACTIONS
TO:
LOCAL ANESTHETICS LIKE NOVOCAINE
BARBITURATES, SEDATIVES OR SLEEPING PILLS ANY METALS (e.g., NICKEL OR MERCURY, ETC)
DO YOU HAVE OR HAVE YOU EVER HAD THE FOLLOWING:
RHEUMATIC HEART DISEASE OR RHEUMATIC FEVER PATIENT'S DENTAL HISTORY PATIENT'S NAME________________________________________________________ DATE OF BIRTH__________________________ REASON FOR THIS VISIT_________________________________________________________________________________________________________ WHEN WAS YOUR LAST DENTAL VISIT_________________________________ WHAT WAS DONE_________________________________________ HOW OFTEN DID YOU VISIT THE DENTIST BEFORE THEN___________________________________________________________________________ PREVIOUS DENTIST (NAME AND LOCATION)______________________________________________________________________________________ HAVE YOU HAD A COMPLETE SERIES OF DENTAL FILMS (X-RAYS) TAKEN WHEN/WHERE____________________________________________ HOW OFTEN DO YOU BRUSH YOUR TEETH______________________ HOW OFTEN DO YOU FLOSS YOUR TEETH__________________________ IS YOUR DRINKING WATER FLUORIDATED_______________________________________________________________________________________ DO YOUR GUMS BLEED WHILE BRUSHING OR FLOSSING DO YOU BITE YOUR LIPS OR CHEEKS FREQUENTLY ARE YOUR TEETH SENSITIVE TO HOLD OR COLD HAVE YOU NOTICED ANY LOOSENING OF YOUR TEETH LIQUIDS/FOODS ARE YOUR TEETH SENSITIVE TO SWEET OR SOUR DOES FOOD TEND TO BECOME CAUGHT BETWEEN YOUR DO YOU HAVE ANY SORES OR LUMPS IN OR NEAR YOUR EVER WORN A BITE PLATE OR OTHER APPLIANCE MOUTH HAVE YOU HAD ANY HEAD, NECK OR JAW INJURIES HAVE YOU EVER HAD ANY DIFFICULT EXTRACTIONS HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING HAVE YOU EVER HAD ANY PROLONGED BLEEDING DO YOU WEAR DENTURES OR PARTIALS ~ IF YES, DATE INSTRUCTIONS REGARDING THE CARE OF YOUR TEETH AND GUMS
IF YOU COULD CHANGE ANYTHING ABOUT YOUR SMILE, WHAT WOULD YOU CHANGE?
AUTHORIZATION AND RELEASE
I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INSURANCE COMPANY TO PAY DIRECTLY TO THE DENTIST INFORMATION TO THE BEST OF MY KNOWLEDGE. THE ABOVE OR DENTAL GROUP INSURANCE BENEFITS OTHERWISE QUESTIONS HAVE BEEN ACCURATELY ANSWERED. I UNDERSTAND PAYABLE TO ME. I UNDERSTAND THAT MY DENTAL THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL MY HEALTH. I AUTHORIZE THE DENTIST TO RELEASE ANY BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR INFORMATION INCLUDING THE DIAGNOSIS AND THE RECORDS OF ANY PAYMENT OF ALL SERVICES RENDERED ON MY BEHALF OR TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE TO THIRD PARTY PAYORS AND/OR HEALTH PRACTITIONERS I AUTHORIZE AND REQUEST MY X_______________________________________DATE____________ SIGNATURE OF PATIENT OR PARENT/GUARDIAN IF MINOR. DOCTOR'S COMMENTS ____________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ ________________________________________________________________________ SIGNATURE DATE

Source: http://www.locuststreetdental.com/pdf/Patients%20Medical%20History.pdf