Lab Exercise #06: Forms


Basic Patient Information

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will recieve. That you for answering the following questions.


Basic Questions

Are you under a physician's care now?
Yes No   If yes, please explain

Are you on a special diet?
Yes No   If yes, please explain

Have you ever been hospitalized or had a major operation?
Yes No   If yes, please explain

Have you had a serious neck or head injury?
Yes No   If yes, please explain

Are you taking any medication?
Yes No   If yes, please explain

Have you taken Phen-Fen or Redux? Yes No
Have you taken Fosamax, Boniva, or Actonel? Yes No
Do you use tobacco? Yes No
Do you use controlled substances? Yes No

Women: Are you? Taking oral contraceptives? Yes No   Nursing? Yes No
  Pregnant/Trying to get pregnant? Yes No
Are you allergic to any of the following? Aspirin
Penicillin
Local Anesthetics
Acrylic
Metal
Latex
Sulfa drugs
Other
If yes please explain
Do you have, or have you had, any of the following? Anemia
Cancer
Convulsions
Diabeter
Epilepsy
Stroke
Pacemaker
Other
If yes please explain

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my resposibility to inform the medical office of any changes in medical status.

Initials of patient, parent, or guardian     Date:


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