Microsoft word - 2012.1.23 confidential health information new_0_.doc
Are you taking or have you taken any of the following?
Yes No Drugs for osteoporosis such as Fosomax or Boniva
List any medications that you are taking.
(circle appropriate answer)
Yes No Do you have regular dental checkups? Date of last exam:
Yes No Have you had any trouble with previous dental treatment? Explain:
Yes No Do you want to keep your own teeth for your entire life?
Yes No Are you happy with the appearance of your teeth?
Yes No Do your gums bleed when you brush your teeth?
Yes No Have you noticed any sores or lumps in your mouth?
Yes No Do you have any pain or clicking in the jaw joint?
Yes No Do you suffer from pain in the mouth, face, eyes, neck, or throat?
Yes No Are you allergic to any metals or dental materials?
Yes No Are you allergic to latex?
Yes No Do you have any other dental concerns not listed above? Additional Comments:
I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. I will notify the doctor at subsequent appointments of any changes to my health or medications. Patient signature __________________________________________________ Date _____________________ (or) Patient’s representative _________________________________ Relationship to patient _______________ Reviewed by _____________________________________
Robert E. Blew, D.D.S. | Bryan C. Blew, D.D.S.
604 35th Avenue | Moline, IL 61265 | Phone 309.797.4336 | [email protected]
CONFIDENTIAL HEALTH INFORMATION
Date of Birth
Why are you seeking dental care? ________________________________________________________________ Current State of Health
(circle appropriate answer)
Have you been hospitalized within the last two years?
Are you currently under the care of a physician?
Please list the name of your family physician and any other specialists that you see at least once a year.
___________________________________________________________________________________________ Medical History
(circle appropriate answer) Do you have or have you experienced any of the following?
Allergic reaction to drugs or medications
Have you had any illness not listed above? List:
Yes No Women: Are you pregnant, nursing, or taking oral contraceptives?
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