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Microsoft word - health history form

CONFIDENTIAL HEALTH HISTORY

I. CIRCLE APPROPRIATE ANSWER (Leave blank if you do not understand the question)
Has there been a change in your health within the last year? Have you gone to the hospital or emergency room or had a serious illness in the last three years? Are you being treated by a physician now? If YES, explain Have you had problems with prior dental treatment?
II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING? (Please Circle)

III. HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING? (Please Circle)
IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING? (Please Circle)
Local anesthetic (Novacaine or Xylocaine)
V. ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS? (Please Circle)

VI. WOMEN ONLY
If YES, what month? ________________________ VII. ALL PATIENTS
Do you have or have you had any other diseases or medical problems NOT listed on this form? 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.
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 medication. 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.

Signature of Patient (Parent or Guardian)
Signature of Dentist

………………………………………………………………………………………………………………………………………………
MEDICAL UPDATES
I have reviewed my Health History and confirm that it accurately states past and present conditions.
DATE PATIENT

SIGNATURE
INITIALS
_______________________________
________________________________________
_________
_______________________________
________________________________________ _________
_______________________________
________________________________________
_________
_______________________________
________________________________________
_________
_______________________________
________________________________________
_________
_______________________________
________________________________________ _________
_______________________________
________________________________________
_________
_______________________________
________________________________________
_________

Source: http://www.batesoleortho.com/forms/HealthHistory.pdf

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Microsoft word - inleiding in de orthomanuele geneeskunde - juni 2005.doc

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