Microsoft word - medical history.doc

William D Kenfield DDS LLC
Patient Information

Patient Name_____________________________________________ Phone# ( )____________Cell# ( )_____________
Address ______________________________________ City ________________________State ____ Zip ________________ Social Security #_______________________Birth Date__________________ Male [] Female [] Marital Status__________ Parent/Guardian/Responsible Party Information
Name ______________________________________________ E-mail____________________________________________ Address_______________________________________City_________________________State_____Zip_______________ Employer___________________________________________________________Phone# (____) ______________________ Insurance Company Name_____________________________________________ Phone# (____) ______________________ Medical History
[] No [] Yes explain_______________________________________________ [] No [] Yes explain_______________________________________________ [] No [] Yes explain_______________________________________________ Have you ever had a serious head/neck injury? [] No [] Yes explain_______________________________________________ Have you taken bisphosphonates including Actonel, Fosamax, Boniva, Skelid, Zometa, Aredia, Didronel, or Clodronate? [] No [] Yes list___________________________________________________ [] No [] Yes explain________________________________________________ [] No [] Yes type__________________________________________________ Are you taking any medicines, drugs, pills, or herbal supplements including garlic, ginseng, genko, feverfew, vitamin E or fish oil? [] No [] Yes list_____________________________________________________
Are you allergic to any of the following? Please check the box below
[] Penicillin [] Codeine [] Latex [] Aspirin [] Local Anesthetics [] Acrylic [] Metal [] Other__________________
Women, are you:
Pregnant or trying to get pregnant? [] Yes [] No Taking birth control [] Yes [] No Nursing [] Yes [] No
Do you have, or have you had any of the following?
AIDS/HIV
Heart Valve Replaced [] Yes [] No Pregnancy [] Yes [] No Recent Weight Loss [] Yes [] No Have you had any serious illness not listed above? [] No [] Yes please explain______________________________________ _____________________________________________________________________________________________________ Dental History
Do you have a specific dental problem? Please describe________________________________________________________ _________________________________________________________________________________________ [] Yes [] No Do you have dental examinations on a routine basis? Last visit_______________________________________ [] Yes [] No Do you think that you have cavities or gum disease? _______________________________________________ [] Yes [] No Do your gums bleed? ________________________________________________________________________ [] Yes [] No Have you ever had periodontal (gum disease) treatment? ____________________________________________ [] Yes [] No Do you ever have popping, clicking, or discomfort in your jaw joint? Do you brux or grind your teeth? _______ [] Yes [] No Do you have pain near your ears or difficulty opening or closing your mouth____________________________ [] Yes [] No Do any of your teeth hurt when you bite?_________________________________________________________ [] Yes [] No Do you like your smile? If no, why? ____________________________________________________________ [] Yes [] No To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status, or if my medicines change, I will inform the dentist or his staff at my next appointment. I understand that payment is my obligation regardless of insurance or any third party involvement. ___________________________________________ Date________________ Relationship to Patient __________________ Signature of Patient, Parent, or Guardian 2nd year signature_____________________________ Date________________ Relationship to Patient __________________ 3rd year signature_____________________________Date ________________ Relationship to Patient __________________ Referral Information
Whom may we thank for referring you to our office? [] Another Patient [] Yellow Pages [] Radio Advertisement [] Web Site [] Other Name of person referring you to our practice _________________________________________________________________ Who, if anyone (spouse, family member etc.), may we discuss your treatment with or release information to? _____________________________________________________________________________________________________

Source: http://www.kenfielddds.com/pdf/medical_history.pdf