T/lJ,,o/ tUith*y, c7

[Pages:1][7

T/l"J,,o/ tUith*y,

c7

Physician'sName

Date of last visit

Phone(

)

Pharmacy

Phone(_).

Please check (E/) "yes" or "no" to indicate if you have had any of the following:

AIDS Anemia ArthritisR, heumatism Asthma BackProblems Cancer ChemicaDl ependency Chemotherapy CirculatorPyroblems CortisoneTreatments Coughp, ersistenotr bloody Diabetes Emphysema Epilepsy Faintinogr dizziness Glaucoma Headaches HeartProblems HepatitisType-----.-.-.Herpes

lYes E No lYes n No nYes n No nYes fl No

nYes ENo' nYes I No nYes n No nYes n No nYes n No nYes n No lYes n No nYes n No nYes n No nYes n No nYes [] No nYes n No nYes n No nYes n No nYes ! No EYes n No

High Blood Pressure

HIV Positive

Jaundice

Jaw Pain

..-

Kidney Disease -

Liver Disease

Low BloodPressure

NervousProblems

PsychiatricCare

RadiationTreatment

RespiratoryDisease

Scarlet Fever

Shortnessof Breath

SinusTrouble

Skin Rash

Special DietAtVeighLt oss

Stroke

Swollen Feet or Ankles

S w o l l e nN e c k G l a n d s

Thyroid Problems

IYes n No nYes n No lVes n No nYes n No nYes n No nYes n No nYes n No nYes n No nYes n No nYes n No nYes n No lYes n No nYes n No nYes n No lYes n No nYes n No nYes I No nYes [] No nYes n No nYes n No

Tonsillitis Tuberculosis Ti:morsor Growths Ulcer VenereaDl isease

Haveyou everhad or been diagnosedwith: ArtificiaHl eartValves ArtificiaJl oints,Screws,

Pins,etc. Bleedinagbnormallwy,ith

extractionosr surgery BloodDisease CongenitaHleartLesions HeartMurmur HerniaRepair MitralValveProlapse Pacemaker RheumaticFever

Haveyou ever hadany complicatione followingdentaltleatment? [ Yes ! No

Haveyouevertakenanyof thesemedicataons? Are you allergicto:

BloodThinners

nYes n No Aspirin

lf yes, pleasedescribe

Haveyoueverbeenhospitalizedor do you have

anyotherhealthconcerns?

nYes n No

Coumadin Warfarin Diet Medications Dexfenfluramine Fen-phen

nYes n No Barbiturates

E Yes n No flYes n No

'\

Codeine fiiuKloten

n Yes n No '" Latex

nYes n No LocaAl nesthesia

lf yes, pleasedescribe

Pondimin Redux

I Yes n No n Yes n No

Metals(i.e.gold) Penicillin

WomenA: reyoupregnant? lYes n No

Levoxyl

fl Yes n No Sulfa

Due date

Synthroid

nYes n No

Areyounursing?

nYes fl No

PleasePRINTall medicationsnowtaking:

Takingbirthcontropl ills?

IYes n No

SIGNATURES

Tothebestofmyknow|edge,theabovein'ormationiscomp|eteandcorrect.|understandthatitiSmyresponSibi|ityto

nYes E No nYes n No flYes n No nYes n No nYes n No

nYes n No

nYes ! No

nYes ! No lYes n No lYes n No nYes E No nYes n No nYes n No IYes n No nYes n No

nYes I No nYes E No nYes n No [Yes n No lYes n No nYes n No nYes n No nYes n No lYes n No

InsuranceAssignment: I certifythat l, and/orniy debendent(s)h, aveinsurancecoveragewith .

N a m e o f . l n s u r a n c eC o m p a n y ( i e s )

and assigndirectlyto

Dr.a||insurancebenefits,ifany,otherwisepayab|etomeforserVicesrendered.|understandthat|amfinancia||Vresponsib|

all chargeswhetheror not paidby insuranceI. authorizethe use of my signatureon all insurancesubmissions.

The above-named octormayuse my healthcareinformationand maydisclosesuchinformationto the above-namedInsuranceCompany(iesa)ndtheiragentsforthe purpose6t obtaining

or one yearfromthe datesignedbelow.

Authorizationto ReleaseProtectedHealthInformation: I understandthat theremay be a needto consultwith otherhealthcare providersI. voluntarilvauthorize

Dr. Nameof DoctorDisclosingPHI

to use and/ordisclosemy ProtectedHealthInformation(PHl)relatedto Describein detailthe ProtectedHealthlnformation

you are authorizingto be usedand/ordisclosed

The Informationwill be usedand/ordisclosedfor the purooseof Describeeachpurposefor whichyou are authorizing

your ProtectedHealthInformationto be usedand/ordisclosed.

Nameof DoctorReceivingPHI

to receiveand use the information.

This authorizationwill end when my currenttreatmentplan is completedor one year from the date signed below.I understandthat once the informationis releasedit mby be redisc|oSedbytherecipientandmayno|ongerbeprotectedby|edera|privacyregulations.|understandthat|may

aboVe-nameddoctordisc|osingthePH|.HoWeVer,ifldoreVokethisauthorization,itwi||nothaVeanyeecton

totheirreceiptofthereVocation.|understandthatmytreatmentcannotbeconditioned

Signatureof Patient,Parent,Guardianor PersonalRepresentative Pleaseprintnameof Patient,Parent,Guardianor PersonaRl epresentative

Relationshioto Patient

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