We Would Like to Get to KNow You Better

 

 

 

M F Single Married Seperated Divorced

 

 

We Want to Take Care of Your Concerns and Needs First










Yes No

 

Yes No

 

(Excellent, Good, Fair, Poor):

 

 

 

 

For Insourace Purposes

 


 

 

 

 

 

 

Medical History

 

 

 

Yes No Yes No Yes No

 

Y N Anemia
Y N Arthritis, Rheumatism
Y N Artificial Heart Valves
Y N Artificial Joints
Y N Asthma
Y N Blood Disease
Y N Blood Transfusion
Y N Cancer
Y N Chemical Dependency
Y N Chemotherapy
Y N Circulatory Problem
Y N Cortisone Treatments
Y N Diabetes
Y N Epilepsy
Y N Fainting
Y N Glaucoma
Y N Headaches
Y N Heart Murmur
Y N Heart Problem
Y N Hemophlia
Y N Heptatitis
Y N HighBlood Pressure
Y N HIV/AIDS
Y N Jaw Pain
Y N Kidney Diseases
Y N Liver Diseases
Y N Mitral Valve Prolapse
Y N Nervousness
Y N Pacemaker
Y N Radiation Treatment
Y N Respiratory Disease
Y N Rheumatic Fever
Y N Shortness of Breath
Y N Stroke
Y N Swelling of Feet/Ankles
Y N Thydoid Problems
Y N Tuberculosis
Y N Ulcer
Y N Venereal Disease
Are You Allergic to:
Y N Latex
Y N Codeine
Y N Local Anesthetic
Y N Penicillin
Other
Please List Any Medical
Conditions Not Listed Above:
Yes No Yes No


I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT THE ABOVE INFORMATION IS CORRECT AND THAT IF THERE ARE ANY CHANGES IN THE ABOVE, I AGREE TO NOTIFY MY DENTIST BEFORE MY NEXT VISIT.
CONSENT FOR TREATMENT: I hereby grant authority to the dentist(s) in charge of the care of the patient whose name appears on this Health Hstory form, to administer such anesthetics, analgesics, sedatives, nitrous oxide sedation; and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient. I have been informed of all possible complications of the procedure, anesthetics and/or drugs. I also acknowledge that any photographs taken can or will be used for teaching, marketing or demonstration pourposes.
I have received a copy of the Dental Medical Fact Sheet as required by law.
Authorization must be signed by the patient, or by nearest relative in the case of a minor or when the patient is physically or mentally incompetent.

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