National health and nutrition examination survey iii oral examination component prepared by. But you can use it to get started on your family health. Americas leading advocate for oral health as required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Feel free to ask any questions about the information being requested. Please complete both sides of this dentalmedical history form so that we may provide you with the best possible dental care. Yes no has there een a change in your health within the last year. Have you ever had serious trouble with previous dental work. Medical history record pdf template is mostly used in order to provide significant information about the health history, care requirements, and.
Health history form ada american dental association. Early signs of malocclusion in the primary and mixed dentition. Have you had a joint knee, hip, shoulder replaced in the last two years. If you need more room to list medications, please write them on a blank sheet of paper with the required information health maintenance screening test history allergies o no allergies medications. Medical history 8 9 time since your last medical checkup. Please complete both sides of this dental medical history form so that we may provide you with the best possible dental care. I certify that i have read and understand the above and that the information given on this form is accurate, i understand the importance of a truthful healthy history and that my dentist and hisher staff will rely on this information for treating me. Have you ever experienced an allergic or other bad reaction to a medication, injection, material or food of any kind e.
Michigan licensed dentists may not be licensed in identified subspecialties. Circle appropriate answer leave blank if you do not understand the question 1. Health history form american dental association email. Has the patient had an orthodontic consult or treatment. Health history form ada american dental association email. List all reactions to medicines, foods and other agents. Yes no do not know does your child use any other form of fluoride. Many hospitals rely on paperbased forms for this task. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. Confidential american association of orthodontists medical. Please complete the following medical history form honestty. This information is strictly confidential and will not be released to anyone.
I understand the importance of a truthful health history and that my dentist and hisher staff will rely on this information for treating me. The information request below will assist us in treating you safely. What is the most important thing about your visit today. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. First last name nickname what are your goals in coming to our practice today. Family health history form fill out all pages of this form about you, your partner and your families. Y n do you require antibiotics before any dental work. Aside from risk management, a dental health history update form can also keep a dentist informed of any changes in a patients financial or living situation. As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain, your answers are for our records only and will be kept confidential subject to applicable laws.
Have you experienced problems associated with any previous dental work. I acknowledge that my questions, if any, about inquiries set forth. To the best of my knowledge, the questions on this form have been accurately answered. I certify that i have read and understand the above and that the information given on this form is accurate. Signature of patientlegal guardian date comments on patient interview concerning health history. Office practices may vary and patients should contact the dental office for. Early signs of malocclusion in the primary and mixed dentition dr p s viswapurna bds mds morthrcsed fdsrcsed mdtfrcsed. These facts have adirect bearing on your dental health. Yes have you ever had radiation treatment to the head or neck area. The parent or guardian who accompanies the child is responsible for payment at the time of service. This form does not replace the health history form that you fill out at your health care providers office. Others use online forms while some also use pdf forms. Y n do you now or have you experienced paindiscomfort in your jaw tmjtmd.
Nhti concords community college client medicaldental history form all information provided is considered confidential and vital for dental care at nhti concords community college. A thorough and complete history is vital to a proper orthodontic evaluation. Our office adheres to written policy and procedures to protect the privacy of information we receive. It is important that i know about your medical and dental history. So that we may provide you with the best possible care, please complete all parts of this dentalmedical history form. Please check any of the following that apply to you. Do you have a prosthetic heart valve, a history of infective endocarditis heart inflammation, congenital heart disease at birth or a heart transplant. Read the directions for each section they contain important information. Medical history birth date although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. This information is for official and medically confidential use only and will not be released to unauthorized persons.
Past surgical history i have not had any surgical procedures please list any other surgeries and dates attach an additional sheet if necessary. Significant findings from questionnaire or oral interview. The physician should keep a copy of this form in the chart. Rivas, dds, pa corp do you have, or have you had, any of the following. Teeth sensitive to cold, heat, sweets, pressure or brushing circle sores on face or neck that have not healed food catches between teeth clenching or grinding sounds in jaw or ear while eating frequent headaches unfavorable dental. If you are completing this form for another person, what is your relationship to that person. What has been your experience with the dentist in the past. Great expressions dental centers branded practices are independently owned and operated in specific states by licensed dentists and their professional entities who employ the licensed professionals providing dental treatment and services. Have you ever had any abnormal bleeding associated with previous extractions, surgery, or trauma. Cancer yesyes no family history of cancer no received radiation treatment yesyes no growth problems no endocrine problems yesyes no hormone therapy no latexmetal allergy yes no nervous disorders bone disordersbone loss yes no diabetes seizuresepilepsy yesyes no handicapsdisabilities no. Person under investigation pui and case report form. Thank you for taking the time to completely fill out this questionnaire. New patient medical history form allergy allergic reaction medications please list all dose times per day mg.
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