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Confidential health history

CONFIDENTIAL HEALTH HISTORY

Patient Name: ______________________________________________________________ Date of Birth: ______________________
I. CIRCLE APPROPRIATE ANSWER (Leave blank if you do not understand the question)
1. Yes No
If NO, explain__________________________________________________________________________ Has there been a change in your health within the last year? If YES, explain_________________________________________________________________________ Have you gone to the hospital or emergency room or had a serious illness in the last 3 years? If YES, explain_________________________________________________________________________ Are you being treated by a physician now? If YES, explain______________________________________ Date of last medical exam_________________________ Reason for exam__________________________ Have you had problems with prior dental treatment? If YES, explain_________________________________________________________________________ Date of last exam_______________________Name of last treating dentist__________________________ If YES, explain_________________________________________________________________________
II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING? (Please check)
III. HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING? (Please check)
Yes No

IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING? (Please check)

Others: ___________________________________________________________
V. ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?
Yes No
PLEASE LIST ALL MEDICATIONS YOU ARE TAKING:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________


VI. WOMEN ONLY


VII. ALL PATIENTS

Do you have or have you had any other diseases or medical problems NOT listed on this form? If YES, please explain: ____________________________________________________________________ _______________________________________________________________________________________ Have you ever been pre-medicated for dental treatment? If YES, why? ______________________________ Have you ever taken Fen-phen? If YES, when_________________________________________________ Is there any issue or condition that you would like to discuss with the dentist in private?
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician. Patient signature: X_______________________________________________ Date: ________________________________ Physician’s name: _______________________________________________ Physician’s address: _____________________________________________________________________________________
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely
and accurately. I will inform my dentist of any change in my health and/or medications. Further, I will not hold my dentist, or
any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
X
Signature of Patient (Parent or Guardian) ------------------------------------------------------------------------------------------------------------------------------------------------------------------- MEDICAL UPDATES I have reviewed my Health History and confirm that it accurately states past and present conditions. DATE ___________________ _________________________ ________________ ___________________ _________________________ ________________ ___________________ _________________________ ________________ ___________________ _________________________ ________________ ___________________ _________________________ ________________ ___________________ _________________________ ________________ ___________________ _________________________ ________________

Source: http://www.bestchoicedental.com/images/Medical%20History%20Adult.pdf

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