PatientPop
MEDICAL HISTORYAre you taking any medications? (Please list all or attach list) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have or had any of the following diseases, medical conditions or procedures?Y N Heart attack / strokeY N Sinus ProblemsY N Severe / Frequent HeadachesY N Heart surg./ pacemakerY N Stomach ProblemsY N Frequent neck painY N Heart MurmurY N Psychiatric ProblemsY N Back ProblemsY N Rheumatic FeverY N Venereal DiseaseY N Cosmetic SurgeryY N Mitral Valve ProlapseY N Alcohol / Drug abuseY N Radiation treatmentY N Artificial ValvesY N TuberculosisY N ChemotherapyY N Heart DiseaseY N Jaw Problems TMJY N AsthmaY N Congenital Heart DefectY N Cancer / TumorsY N Difficulty BreathingY N Chest PainY N ShinglesY N Diabetes / HypoglycemiaY N Scarlet FeverY N Hepatitis A, B, CY N LeukemiaY N NervousnessY N HIV + / Aids / ARCY N AnemiaY N Thyroid ProblemsY N ArthritisY N High / Low Blood PressureY N Kidney ProblemsY N Artificial Joints Y N Bleeding ProblemsY N Liver ProblemsY N Emphysema Y N Glaucoma Y N Respirator Problems Y N Fainting / Seizures / EpilepsyPlease list any other surgeries or medical conditions you have or have had: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you allergic to any of the following? * Latex * Penicillin / Amoxicillin * Tetracycline * AspirinDental Anesthetics * Others: _________________________________________________________Please list all allergies: __________________________________________________________________Do you use Alcoholic beverages? ______Tobacco? _______How often? ____________How long? _____FOR WOMEN: Are you taking Birth Control Pills? Y N Are you Pregnant? Y N We invite you to discuss with us any questions regarding our services. The best Dental Health Services are based on a friendly, mutual understanding between provider and patient. Our Policy requires payment in full for all services rendere4d at the time of visit, unless other arrangements have been made. If your account is not paid within 90 days of the date of services and no financial arrangements have been made, you will be responsible for legal fees, collections agency fees, interest charges and any other expenses incurred in collecting your account. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorized the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is MY RESPONSIBILITY to inform this office of any changes to information I have provided. Signature ______________________________________ Date _____/____/_____. ................
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