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Microsoft word - medical history
Health Information and History
_________________________________________________________________Date of Birth:_
Cell Phone:_________________ Employer:____________________
Business Phone:_______________ Emergency Contact:
______________________________________ 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. Within 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 ANY special precautions before 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 list with you, give that to the receptionist instead.) Prescribed:____________________________________________________________________________________ _____________________________________________________________________________________________ Over-the-counter (OTC) medications (such as 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 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 had any reaction to any of the following drugs?
___Penicillin (or related drugs)
___Aspirin/Ibuprofen (Advil, Motrin, Nuprin)
___NSAID (Celebrex, Vioxx, Anaprox) ___Iodine
6. Are you allergic to or have you ever experienced an unusual reaction to:
7. Have you had an allergic reaction or unusual response to ANY other medications, drugs, pills, or treatments? □ Yes □ No
If Yes, please list:_______________________________________________________________________________
8. Do you have, or have you ever had, any of the following?
(Please check Yes or No for each question.)
Tuberculosis, emphysema, lung disorder ___ ___
If Yes, type & date_______________________
If Yes, date____________________________
Rheumatic heart disease/rheumatic fever ___ ___
Heart valve damage/mitral valve prolapse ___ ___
Epilepsy, feinting, or other seizure disorder ___ ___
Ulcers, acid reflux, or stomach problems
HIV, AIDS, radiation immune problem) ___ ___
A sexually transmitted disease (STD) ___ ___
Excessive bleeding from a cut or incident ___ ___
Artificial joint, joint surgery, or prosthesis
If Yes, would you like to be treated for it? ___ ___
If yes, what joint or area:__________________
Hepatitis, jaundice, or other liver problems ___ ___
When was the operation done:_____________
Are you pregnant?
If Yes, what is your due date:______________
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:______________________________________________________________________________ 10. Why do you seek dental treatment?
______________________________________________________________ 11. Do you consider the condition of your oral health:
Excellent____ Good____ Fair____ Poor____
12. When was your last dental visit?
____________________ What was done?
_____________________________ 13. Have you had any problems associated with any previous dental treatment?
□ 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. I understand that all x-rays taken in this office shall remain the property of Dr. Matrullo. Should I desire a transfer of these records, I will be responsible for a duplicating fee. I understand that all charges are my ultimate responsibility. I further understand that all balances remaining after insurance coverage (if any) has fulfilled its obligation are my responsibility. I understand that if I do not pay any amount which is owed you within 30 days after receipt of your statement of services rendered, then I will be in default of this agreement, and I will pay interest and the reasonable cost which you incur to col ect the balance owed you, including reasonable attorney’s fees to the extent permitted by law. Signature_________________________________________________________ Date_____________________
(Parent or guardian, if patient is a minor)
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**
I, ________________________________, have received a copy of this office’s Notice of Privacy Practices.
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:
o Communications barriers prohibited obtaining the acknowledgement
o An emergency situation prevented us from obtaining acknowledgement
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