Bellmore Family Dental Office Policies - Signature On File Form Page 3
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2
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4A'OA.
American Dental Association
HEALTH
HISTORY
FORM
Name:
Home
Phone: (
Business
Phone:
(
ARST
MIDDlE
Address:
City:
State:
Zip
Code:
P.O.BOX
Of
Mang
Addte&s
Occupation:
Height:
Weight:
Date of
Birth:
Sex:
MO
FO
S8#:
Emergency Contact:
Relationship:
Phone: (
if you are completing this form for another
person,
what is your relationship to thai
person?
NAME
RElATKlNSHIP
For the following
questions,
please (Xl whichever
applies, your
answers are for
our
records only and will be
kept
confidential in accordance with applicable laws.
Please note
that
during your
initial
visit you will be asked some questions about your responses to this questionnaire and there may be
additional
questions
concerning your health. This information is vital to allow us to provide appropriate care for
you.
This office does not use this information to discriminate.
DENTAL
INFORMATION
Do your gums bleed
when you
brush?
Have
you
ever had orthodontic
(braces) treatment?
Are your teeth sensitive to
cold,
hot,
sweets
or
pressure?
Do you have earaches or neck
pains?
Have you had any periodontal (gum) treatments?
Do you
wear
removable dental appliances?
Have you had a serious/difficult problem associated
with any previous dental treatment?
If
yes,
explain:
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
How would
you describe your current
dental
problem?
Date
of your last dental exam:
Date
of
last dental
x-rays:
What was done at that time?
How do you
feel
about the
appearance
of your teeth?
MEDICAL
INFORMATION
Don't
Don't
Yes No Know
Yes No Know
If you answer yes to any of the 3
items'
below,
Are
you
taking
or
have you
recently
taken any
medicine(s) including non-prescription medicine?
0
0
0
please'
stop and return this form to the receptionist.
If
yes,
what medicine(s) are you
taking?
Have you had any of the following diseases or
problems?
Prescribed:
Active Tuberculosis
0
0
0
Persistent
cough
greater
than
a .3week
duration
1:1
1:1
0
Over the
counter:
Cough that produces blood
0
0
0
Are you in good health?
0
0
0
Vitamins,
natural
or
herbal preparations
and/or
diet
supplements:
Has there been any cgange in your general
health within the past year?
0
0
0
Are you
now under
the care
of
a physician?
0
a
0
Are
you taking,
or
have you
taken,
any diet
drugs such
If
yes,
what isfare the
condition(s)
being
treated?
Pondimin
(fenfluramine),
Redux (dexphenfluramine)
or phen-fen
(fenfluramine-phentermine
combination)?
0
0
0
Date of last physical examination:
Do you
drink
alcoholic
beverages?
0
0
0
If yes, how
much alcohol
did you drink in the last
24 hours?
Physician:
In the past
week?
NAME
PHONE
Are you
alcohol and/or
drug
dependent?
0
0
0
ADDRESS
ClTY/S11l.TE
ZlP
If
yes,
have
you
received
treatment? (circleone)
Yes/No
NAME
"""""
Do you use drugs
or other
substances
for
ADDRESS
GfTY/STATE
ZIP
recreational
purposes?
0
0
0
If
yes,
please
list:
Have you had any serious illness,
operation,
Frequency of use
(daily,
weekly, etc.):
or been hospitalized in the past 5 years?
0
0
0
If
yes,
what was the illness or problem?
Number of years of recreational drug use:
Do
you
use tobacco
(smoking,
snuff,
chew)?
0
0
0
If
yes, how interested
are
you
in
stopping?
(circleone)
Very
I
Somewhat / Not interested
Do you wear contact
lenses?
0
0
0
PLEASE COMPLETE BOTH SIDES
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