MEDICAL HISTORY - Family and Cosmetic Dental Care Updated ______

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MEDICAL HISTORY - Family and Cosmetic Dental Care Updated ______ Powered By Docstoc
					MEDICAL HISTORY - Family and Cosmetic Dental Care

Updated       ________    _________       ________   ________   ________     ________
BP            ________    _________       ________   ________   ________     ________

Name ______________________________________              Date of Birth ________________

Current Physician _________________________ Phone # of Physician________________

Date of last physical exam ______________

1. Are you under medical treatment at this time? Yes                          No
   If so please describe:

2. Are you now taking any medication(s) including non prescription drugs? Yes No
   Please list all medications you are currently taking and why:

3. Have you ever used tobacco ?    Yes      No   How Often? ____________________

4. Have you ever used alcohol?     Yes      No   How Often? ____________________

5. Have you ever used cocaine or other drugs? Yes No
   Please Specify:

6. Have you ever been hospitalized for surgical operations or serious illness? Yes No
   If so, please describe:

7. WOMEN ONLY: (Question #7 Only)
 Are you currently pregnant?        Yes     No
Are you taking Birth Control pills? Yes     No

8. Have you ever had prolonged bleeding following a cut or extraction? Yes          No

9. Have you ever tested positive for HIV/AIDS?                        Yes           No

                                                                (Turn Over / Next page)
10. Circle any of the diseases/conditions listed below that you have or had:
 Heart Murmur          Lung or Respiratory Disease      Joint or Hip Replacement   Diabetes
 Heart Ailment         Sinus Trouble                    Knee Replacement           Hepatitis
 Rheumatic Fever       Asthma                           Arthritis                  Epilepsy
 Stroke                Tuberculosis                     Have taken Fosamax         Liver Disease
 Mitral Valve Prolapse Hay Fever                        Have taken Phen Phen       Latex Allergy
 Bypass Surgery        Fainting Spells                  Tumors or Growths          Kidney Disease
 High Blood Pressure Intestinal Disease                 Mental Health Disease      Blood Disorders
 Heart Valve Replacement                                Hypothyroidism

11. Circle any of the following that you are allergic to or have had a reaction to:
       Local Anesthetics (Novocaine/Lidocaine/etc.)
       Sedatives or Pain Killers
       Other: ________________________________________________

12. Who was your former dentist? ____________________________ Phone:

13. Are you seeing a dental specialist?_________________________

14. Circle any of the following habits you may have:
       Clenching Your Teeth          Cheek Biting    Foreign Objects in Your Mouth
       Grinding of Teeth             Mouth Breathing Thumb or Finger Sucking
       Other: ___________________________________

Authorization and Release:

I certify that I have read and understand the above information to the best of my knowledge.
The above questions have been accurately answered. I understand that providing incorrect
information can be dangerous to my health. I authorize the dentist to release any information
including the diagnosis and the records of any treatment or examination rendered to me or my
child during the period of such dental care to third party payors and/or health practitioners. I
authorize and request my insurance company to pay directly to the dentist insurance benefits
otherwise payable to me. I understand that my dental Insurance carrier may pay less than the
actual bill for services. I agree to be responsible for payment of all services rendered on my
behalf for me or my dependents. If we have to refer your account to a collection agency, you
agree to pay all of the collection costs which are incurred.

________________________________________                      ________________________
Signature of patient/ parent if minor/ legal guardian               Date