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Microsoft word - pt registration- health history form.docx

The Virginia Endodontic Group, LLC
Patient Registration and Health History Form

Please use black pen only. On future visits please be sure to update your medical history.
Patient Information
 Mr.  Ms.  Mrs.  Dr. First name ________________________ M. I. _____ Last name ___________________________
Sex:  M  F Date of birth: / / Email: ____________________________________________
Street: __________________________________________________________________________________________________
City: ____________________________________________State: _____________________Zip: _________________________
Phones: Home: _________________________Business: _________________________Cell: ____________________________
General dentist: ___________________________________Referred by: _____________________________________________
(Please write “same” if referred by general dentist) Other dental specialists you see (i.e., periodontist): _______________________________________________________________ Physician: __________________________________________________Phone: _______________________________________ Emergency Contact In case of emergency contact: ______________________________________  Spouse  Father  Mother  Other Phones: Home: _________________________Business: _________________________Cell: _____________________________ Reason for Visit What is the reason for your visit today? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Please answer the following questions to the best of your knowledge. Although endodontists primarily treat the mouth area, medical problems or medications could have a significant impact on your dental treatment. Your answers are confidential. Y N Are you in good health? Height: __________ Weight: __________ Y N Are you under the care of a physician? Date of last physical examination: ___________________________________ Y N Have you had any illness, operation, or been hospitalized in the past five years? _______________________________ Y N Prosthetic joint implant _____________ Y N Heart valve replacement or vascular graft Y N Damaged heart valves/prosthetic valve Y N Heart attack(s)/myocardial infarction (MI) Y N Rheumatic Fever/Rheumatic Heart Disease Y N Stroke/Transient Ischemic Attack (TIA) Are you taking any of the following medications (please circle)? Alpha-adrenergic blockers, phenoxybenzamine, Levodopa, thyroid hormones: levothyroxine, liothyronine antiarrhythmic agent, Class II, dorzolamide/timolol, levobunolol, metipranolol, nadolol, nadolol/bendroflumethiazide, propranolol, sotalol, timolol CNS stimulants: amphetamine, methylphenidate, ergot derivatives: dihydroergotamine, methysergide Methyldopa, adrenergic neuronal blocking drugs: guanadrel, guanethidine, reserpine Tricyclic antidepressants amitriptyline, amoxapine, clomipramine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, trimipramine Maprotiline Please list all medications you are currently taking: 1. _____________________________________________________________________________________ 2. _____________________________________________________________________________________ 3. _____________________________________________________________________________________ 4. _____________________________________________________________________________________ 5. _____________________________________________________________________________________ 6. _____________________________________________________________________________________ Y N Local anesthetic (novocaine, adrenalin) Y N Latex
Other________________________________________ Other________________________________________
Women
Y N Are you pregnant? If yes, estimated delivery date: ______________________________________
Y N Is there a possibility of pregnancy? Y N Are you taking birth control pills? (Antibiotics, such as penicillin, may alter the effectiveness of birth control pills.
Consult your physician/gynecologist for assistance regarding additional methods of birth control if antibiotics are prescribed.)

All Patients
Y N Have you been told by your physician to take antibiotics prior to dental treatment?
Y N Is there any health condition about which the doctor should know?
Y N Do you wish to speak to the doctor privately about anything?
I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set
forth above have been answered to my satisfaction. I will not hold my endodontist, or any other member of his/her staff,
responsible for any errors or omissions that I have made in the completion of this form. I understand that I am responsible for
notifying my endodontist of any medical changes upon each visit.

Patient Signature: X Date: X
(Parent or Guardian if minor)

I authorize my endodontist and his/her staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and
treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. If medically
necessary, I authorize the release of any information acquired in the course of my examination and treatment.
Patient Signature: X Date: X
(Parent or Guardian if minor)

Doctor: X Witness: X
Acknowledgement of Receipt of Notice of Privacy Practices The doctors and staff at The Virginia Endodontic Group, LLC will use and disclose your personal health information to treat you and to receive payment for the care we provide and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies about your personal health information. The terms of the notice may change with time and we will always post the current notice at our facilities, on our website, and have copies available for distribution. You may refuse to sign this acknowledgement. Patient Signature: X Date: X
(Parent or Guardian if minor)

Source: http://vaendogroup.com/patients/Patient_Registration.pdf

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