Bellmore Family Dental Office Policies - Signature On File Form Page 2
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2
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4Are you allergic to
or
have you had a reaction
to?
Local anesthetics
Aspirin
Penicillin
or other antibiotics
Barbiturates,
sedatives,
or
sleeping
pills
Sulfa
drugs
Codeine
or
other
narcotics
Latex
Iodine
Hay fever/seasonal
Animals
Food (specify)
_
Other
(specify),----
_
Metals (specify),
_
To yes
responses,
specify
type of reaction.
Don't
Don't
Yes No
Know
Have you ever been treated
with bisphosphonates
Yes No Know
0
0
0
for osteoporosis
or other
conditions?
0
0
0
0
0
0
Have you had
an
orthopedic
total joint
0
0
0
(hip,
knee, elbow, finger) replacement?
0
0
0
0
0
0
If
yes, when was this
operation
done?
0
0
0
If you answered
yes to the above
question,
have you had
0
0
0
any complications
or difficulties
with your prosthetic
joint?
0
0
0
0
0
0
0
0
0
0
0
0
Has a physician
or
previous
dentist
recommended
0
0
0
that you take antibiotics
prior to your
dental treatment?
0
0
0
0
0
0
If
yes,
what
antibiotic
and dose?
0
0
0
Name of physician
or
dentist*:
Phone:
WOMEN
ONLY
Are you or could you be pregnant?
Nursing?
Taking
birth
control pills or hormonal
replacement?
0
0
0
0
0
0
0
0
0
Don't
Yes
No
Know
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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0
0
0
0
0
0
0
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0
0
0
0
0
0
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0
0
0
0
0
0
0
0
Please
(X)
a
response
to
indicate
if you have or have not had any of
the
following
diseases
or
problems.
Don't
Know
o
o
o
o
o
o
o
o
o
Abnormal
bleeding
AIDS
or
HIV infection
Anemia
Arthritis
Rheumatoid
arthritis
Asthma
Blood
transfusion.
If
yes, date:
_
Cancer/ChemotherapylRadiation
Treatment
Cardiovascular
disease.
If yes, specify below:
__
Angina
__
Heart
murmur
Arteriosclerosis
__
High
blood pressure
__
Artificial
heart valves
__
low
blood pressure
__
Congenital
heart defects
__
Mitral valve prolapse
__
CongestiYll
heart failure
__
Pacsmaker
__
Coronary
artery
disease
__
Rheumatic
heart
__
Damaged
heart
valves
diseaseIRheumatic
fever
Heart attack
Yes No
0-0
o
0
o
0
o
0
o
0
o
0
o
0
o
0
o
0
Hemophilia
Hepatitis,
jaundice
or liver disease
Recurrent
Infections
If
yes,
indicate type
of
infection:
_
Kidney problems
Mental health
disorders.
If
yes,
specify:
_
Malnutrition
Night sweats
Neurological
disorders.
If
yes,
specify:
_
Osteoporosis
Persistent
swollen glands in neck
Respiratory
problems.
If
yes,
specify
below:
__
Emphysema
__
Bronchitis,
etc.
Severe headaehesJmigraines
Severe or rapid
weight
loss
Sexually
transmitted
disease
Sinus trouble
Sleep disorder
Sores or ulcers in the
mouth
Stroke
Systemic
lupus erythematosus
Tuberculosis
Thyroid
problems
Ulcers
Excessive
urination
Chest pain
upon
exertion
0
0
0
Chronic
pain
0
0
0
Disease,
drug,
or
radiation-induced
immunosurpression
0
0
0
Diabetes.
If
yes,
specify
below:
0
0
0
__
Type
I (Insulin dependent)
__
Type I!
Dry
Mouth
0
0
0
Eating disorder.
If yes, specify:
0
0
0
Epilepsy
0
0
0
Fainting spells
or
seizures
0
0
0
Gastrointestinal
disease
0
0
0
G.E.
Reflux/persistent
heartburn
0
0
0
Glaucoma
0
0
0
Do you have
any disease,
condition,
or problem
not listed above
that you think
I should
know
about?
Please
explain:
NOTE:
Both Doctor
and patient
are encouraged
to discuss
any and all relevant
patient
health
issues
prior to
treatment.
I certify that I have read and understand the
above.
I acknowledge that my questions, if
any,
about
inquiries set forth
above
have been
answered
to my
satisfaction.
I will
not
hold
my
dentist,
or any other member of
his/her staff,
responsible for
any
action
they
take or do not take because of errors
or omissions that
I may
have made
in
the
completion
of
this
form.
SIGNATURE
OF PA.TlENTIt.EGAL
GUARD!AN
I
have reviewed patient's medical history
SIGNATURE
OF DENnST
DATE
Date
Comments
Health
HistorY
Update:
On
a regular basis the patient should be questioned
about any medical history changes, date and comments
notated, along with signature.
Patient
Signature
Dentist
Signature
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