Microsoft word - dentalmedical_history.doc

PATIENT REGISTRATION
Responsible Party: (if someone other than the patient) First Name:____________________________ Last Name:______________________________ Middle Initial:___ Address:__________________________________________ Address 2:_________________________________ City, State, Zip:__________________________________________________ Pager:_______________________ Home Phone:__________________ Work Phone:__________________ Ext: _____ Cell Phone:_____________ Birth Date:____/____/______ Social Security #:___________________ Drivers Lic#:__________________ First Name:____________________________ Last Name:______________________________ Middle Initial:___ Preferred Name: ________________________ Is child a DCFS/foster care client? Yes_______ No_______ Address:__________________________________________ Address 2:_________________________________ City, State, Zip:__________________________________________________ Pager:_______________________ Home Phone:___________________ Work Phone:_______________ Ext:_____ Cell Phone:________________ Birth Date:____/____/______ Social Security #:___________________ Drivers Lic#:__________________ Marital Status: { Married { Single { Divorced { Separated { Widowed E-mail: _______________________________________ { I would like to receive email correspondences Patient is: { Policy Holder (Medicaid/AllKids Card) Medicaid/AllKids ID #:_______________________ Pref. Pharmacy: ______________________ Date of last dental exam/cleaning: ____________________ MEDICAL HISTORY
PATIENT NAME _______________________________________________ Birth Date _____________________________________ Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Please circle the appropriate response. No If yes, please explain: ________________________________________ Have you ever been hospitalized or had a major operation? Yes No If yes, please explain: ________________________________________ Have you ever had a serious head or neck injury? Yes No If yes, please explain: ________________________________________ Are you taking any medications, pills, or drugs? No If yes, please explain: ________________________________________ Do you take, or have you taken, Phen-Fen or Redux? Yes No __________________________________________________________ Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? No __________________________________________________________ No If yes, please explain: ________________________________________ Women: Are you Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local Other If yes, please explain:_____________________________________________________________________________________ Do you have, or have you had, any of the following? Have you ever had any serious illness not listed above? If yes, please explain: ____________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ Comments: ___________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ STATEMENT OR CONSENT FOR HEALTH SERVICES
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. I hereby give my consent to all visits necessary for patient above to receive an oral evaluation, dental treatment, follow-up and maintenance treatment, and for the release of information of health conditions to official agencies and/or private doctors. SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE _____________________ PATIENT/PARENT OR GUARDIAN NAME (Print) _________________________________________________________ IN CASE OF EMERGENCY, PLEASE NOTIFY _______________________________________________ PHONE ____________________________

Source: http://www.lcdph.org/Forms/Dental_RegsMedical2.pdf