Microsoft word - health information and history form_12-03-06.doc
Health Information and History Today’s Date: ______________ Patient’s Name: ______________________________________________________ Date of Birth: ______________
If you are completing this form for another person: Your name: ________________________________________ Phone: ________________ Relationship: ________________
Emergency Contact: (If not listed above)
Name: ____________________________________________ Phone: ________________ Relationship: ________________
Primary Physician: __________________________________ Phone: _________________ City & State: ________________
Date of last physical examination: ______________________ Date of last blood test/work up: ________________________
Other Physicians & Specialists
Name: ___________________________ Specialty: _______________ Phone: ______________ City & State: ____________ Name: ___________________________ Specialty: _______________ Phone: ______________ City & State: ____________
1. With in the last 3 years, have you been hospitalized or had surgery? Yes No
If Yes, please give reasons and dates: __________________________________________________
2. Have you ever been instructed to take ANY medications or take ANY special precautions before any dental appointments*? Yes No
If Yes, please explain: _______________________________________________________________
3. Are you taking ANY drugs, medications, or treatments at this time? Yes No
(If you brought a complete written list with you, give that to the receptionist instead) Prescribed: ________________________________________________________ ________________________________________________________________ Over-the-counter (OTC) medications (such as Aspirin, Advil, allergy medication, sleeping aids, etc):
________________________________________________________________ Vitamins, natural or herbal preparations and/or dietary supplements: ________________________________________________________________ Are you having or have you ever had radiation or chemotherapy treatments*? Yes No
If Yes, for how long?______________ Name of facility performing the treatment :_______________
4. Are you taking or have you ever taken / been treated with a Bisphosphonate (Fosamax)? Yes No 5. Are you allergic to or have you ever experienced an unusual reaction to: 6. Are you allergic to or have you ever had any reaction to any of the following drugs? ___Penicillin (or related drugs)
___Aspirin / Ibuprofen (Advil, Motrin, Nuprin)
7. Have you had an allergic reaction or unusual response to ANY other medications, drugs, pills, or treatments? Yes No
If Yes, please list :___________________________________________________________
Continued on next page… Reviewed By: _________________________ Copyright LED Dental Inc. (12-03-06) Health Information and History (continued) Patient’s Name: ______________________________ 8. Do you have, or have you ever had, any of the following? (Please check Yes or No for each question)
Tuberculosis, emphysema or lung disorder
If Yes, type & date _____________________
If Yes, date ___________________________
Rheumatic heart disease / rheumatic fever
Heart valve(s) damage / Mitral valve prolapse
Ulcers, acid reflux, or stomach problems
(Lupus, HIV, AIDS, radiation immune problem, etc.)
An active sexually transmitted disease (STD) ___ ___
Been treated for any psychiatric condition
Excessive bleeding from any cut or incident
Women Only:
Any artificial joint, joint surgery, or prosthesis
If Yes, what is your due date: ____________
If Yes, what join t or area: __________________
When was operation done: _________________
Hepatitis, jaundice, or other liver problems
Are you taking hormone replacement therapy ___ ___
9. Do you have any other conditions, diseases, or medical problems, or is there ANY other information that you would like us to know about, or that we should be made aware of? Yes No If Yes, please explain: __________________________________________________________________________ ____________________________________________________________________________________________
____________________________________________________________________________________________ ____________________________________________________________________________________________
CONSENT — To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, or medications, this practice will be informed of the changes without fail. I also consent to allow this practice to contact any healthcare provider(s) and to have the patient’s health information released to aid in care and treatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual until further notice.
I understand there are no guarantees or warranties in health or dental care. Signature_______________________________________________________________ Date ___________________
(Parent or guardian, if patient is a minor)
Reviewed By: _________________________ Copyright LED Dental Inc. (12-03-06)
Medication Safety Alert! Use of tall man letters is gaining wide acceptance In the News… Fatal medication errors in the home tive, while use on preprinted order formsA review of US deaths between January 1983 andcompleted our recent survey1 on the use oftall man letters to differentiate products360.5% increase in fatal medication error (FME)with look-alike names. Tall man
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