Form: Medical Dental History – Adult 2018-12-28T05:25:44+00:00

MEDICAL DENTAL HISTORY

MEDICAL/DENTAL HISTORY FORM – ADULT

     Do you have dental insurance?
    YesNo
    If YES, complete the following
     Primary Insurance
     Secondary Insurance
     Has there been any change in your general health?
    YesNo
     Are you being treated for any medical condition or have you been treated within the past 2 years?
    YesNo
     Are you currently being treated by a physician for a specific condition?
    YesNo
     Are you currently taking any medication?
    YesNo
     Do you bleed or bruise easily?
    YesNo
     Have you ever been hospitalized?
    YesNo
     Have you ever received general anesthesia?
    YesNo
     Have you ever had an adverse reaction to local anesthetic?
    YesNo
     Do you have any allergies to medications?
    YesNo
     Do you have any other allergies?
    YesNo
     Do you currently have any of the following conditions?
    Heart Murmur
    Osteoporosis
    Osteopenia
    Rheumatic Fever
    Asthma
    COPD
    Sleep Apnea
    Hepatitis A/B/C/D
    Thyroid Disease
    Mental Illness
    AIDS/HIV
    Herpes / Cold Sore
    Emotional Problems
    Heart Attack
    Angina
    Glaucoma
    Atherosclerosis
    Stroke
    Kidney Disease
    Liver Disease
    Kidney Disease
    Kidney Disease
    Drug/Alcohol Abuse
    Cancer
    Jaundice
    ADHD
    Epilepsy
    Pacemaker
    Organ Transplant
    Arthritis
    Radiation Therapy
    Steroid Therapy
    Stress
    Diabeter Type 1 / Type 2
    Steroid Therapy
    Surgery to Head and Neck
     Is there anything else the doctor needs to know regarding your medical health?
    YesNo
     Do you smoke?
    YesNoQuit
    TobaccoCigarsChewOthers
     Females ONLY
     Are you or could you be pregnant?
    YesNo
     Are you currently breast-feeding?
    YesNo
     Dental History
     Are you currently experiencing any pain or discomfort?
    YesNo
     Are any of your teeth sensitive to
    ColdHotSweetBiting
     Do you have difficulty chewing food or does food get stuck between your teeth?
    YesNo
     Are you unhappy with the overall appearance of your teeth?
    YesNo
     Have you had braces for straightening your face?
    YesNo
     Have you ever had an injury to your jaw or face?
    YesNo
     Does your jaw ever click or pop or cause pain upon opening or closing?
    YesNo
     Are you nervous during dental treatment?
    YesNo
    PATIENT CERTIFICATION AND CONSENT
    I the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted in the reception area and consent to the electronic sharing of information with my insurance company for the purpose of processing insurance claims and determination of benefits. Unless other arrangements have been made assignment of benefits from your insurance company will be set up. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and my dentist. I authorize the dentist to treat me and I assume full responsibility for all fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge.
    ___________________________________________________
    SIGNATURE (PARENT OR GUARDIAN IF UNDER 16)

    To be signed at your appointment

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