Microsoft word - med history[1].doc

Patient Information
Surname_________________________________ First Name __________________________ Initial__________ Date of Birth (DD/MM/YYYY) ______________________ Sex M □ F □
Address ____________________________________________________________________ Apt # __________
City __________________________________ Province ____________________ Postal Code _______________
Home Phone# (_____)-______________ Cell# (______)_______________ Business# (______)______________
Occupation___________________________ Email__________________________________________________
IN CASE OF EMERGENCY NOTIFY: NAME__________________________________________________
RELATIONSHIP_____________________________________PH# (_____)_____________________________
Date of Last Medical Visit _____________________ Reason for Visit____________________________________
HEALTH HISTORY – If YES, please describe
Are you currently in the care of a physician? Has there been any change in your general health in the past year? Are you now being treated for any medical condition or have you been treated within the past two years? Have you ever had a serious illness, operation, or been hospitalized? Are you currently taking any medications including prescription, over the counter or herbal? If YES, please fill out (Women only) Are you pregnant? YES □ NO □ Due Date __________________________ Are you taking birth control? YES □ NO □ MEDICATION
FREQUENCY
Do you have or have you ever had any of the
Have you ever had any UNUSUAL reaction to
following?
Y N any of the following? – If YES, please describe
DENTAL HISTORY – If YES, please describe
Do you have problems with your jaw? (pain, limited opening, locking, popping) Are there any growths or sore spots in your mouth? Have you noticed any changes in your teeth in the last 5 years, become shorter, thinner, or worn? Do you clench or grind your teeth in the daytime or at night? Have you ever been diagnosed with periodontal disease? Do you ever have a dry or burning mouth? Are you anxious of dental treatment? On a scale of 1-10 ______ Have you ever been advised to take antibiotics prior to a dental treatment? Have you ever been disappointed with the appearance of previous dental work? Why did you leave your previous dentist? Do you have any current dental concerns? How did you hear about our practice? ________________________ Who can we thank for your referral? ___________________ When was your last dental visit? __________________________ What was it for? _____________________________________ What can we do to make your visit more comfortable? ___________________________________________________________ I HEREBY CERTIFY THAT THIS MEDICAL HISTORY IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
I CONSENT TO THE PERFORMING OF THE DENTAL PROCEDURES AGREED TO BE NECESSARY OR ADVISABLE, INCLUDING
THE USE OF LOCAL ANESTHTIC (FREEZING) OR ANY DRUGS INDICATED.

PLEASE PRINT ______________________________________________ SIGNATURE _______________________________________________

Source: http://iamplace.biz/~bitedent/wp-content/uploads/2011/12/Med-History.pdf