Patient History Form

Health information is gathered for treatment purposes only. This information enables the provision of optimal dental care and helps in avoiding compromise of the patients general medical health.

Note: So that this dental practice can provide the highest standard of care, please fill in this form carefully and throughly.



 Mr. Mrs Ms Other
























Notice to insured patients regarding dental benefits insurance

Item number on your statement represent as accurately as possible the procedures performed, but in no way are they a claim on anyone other than the patient for whom they were performed. The eligibility of the patient, or the procedures, to attract refunds, and rates of those refunds, are determined by the conditions of the patient's Health Insurance Policy. We accept no responsibility, to either party, for any decision the insurer may make regarding the refund of monies to the patient

HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE INDICATE:

Yes     No

High Blood Pressure

Diabetes

Heart ailment

Thyroid problems

Rheumatic fever

Excessive bleeding or blood disorder

Asthma, Chest or breathing problems

Epilepsy

Tuberculosis

Hepatitis

Stomach or bowel problems (eg ulcer )

AIDS/HIV

Kidney Disease

Bone Disorders or diseases

Do you smoke ?

How many ?
/day

Would you like to stop ?


Would you like to discuss these questions in private with the dentist ?

Do you have artificial hip, heart valve or other prosthetic implant ?

Have you ever had problems with dental treatment ?

Are you presently under medical care ?

Are you taking any drugs, medicines or tablets ? (Please list)

Female patients, Are you pregnant ?

Do you have alergies?


THANK YOU FOR YOUR ASSISTANCE IN COMPLETING THIS FORM AS FULLY AS POSSIBLE

Ticking this box certifies that

I have completed this questionnaire to the best of my knowledge, and understood that failure to make a full disclousure may place ME at undue medical risk. I understand that notes, radiographs (x-rays) and models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. I also give my permission for the practice to use the above contact details to send me appointment and checkup reminders.

I have read and understood the PRIVACY CONSENT DOCUMENT and consent to the collection and use of my health information.

ON FUTURE VISITS ANY CHANGES TO THE ABOVE SHOULD BE ADVISED.
WORKING FOR THE COMMUNITY'S DENTAL HEALTH © ADAVB INC. 2004