Dreamweaver Template File for Dr Sam Parsi website

Patient Record

Mr. Mrs. Ms. Miss. First Name Middle Initial Last Name

Purpose of this appointment

Date of Birth Married Single Divorced Separated Widow(er)

Home Address City Zip

Spouse Name Home Phone

Your Employer Address Phone

Spouse Employer Address Phone

Person Responsible for this Account: Name Middle Initial Last Name

Address if Different from Above

Name of Dental Insurance Company GRP# Name of Insured

Are any members of your family patients here?

Name and Address of Nearest Relative (other than Spouse)

Recommended by

Name of Previous Dentist

Name and Address of Physician Phone

Consent

I hereby consent to the examination, x-rays, use of anesthetics, analgesia, antibiotics and other medication required, and the performace of all dental treatment the doctor may consider necessary for good health.

Signed Date

Health History

I. Please check the appropriate boxes below. Leave the boxes blank if you do not understand the question:

Yes No

Is your general health good?

Yes No

Has there been a change in your health within the last year?

Yes No

Have you ever beeen hospitalized or had a serious illness in the last three years?

Why?

Yes No

Are you being treated by a physician now?

For what?

Date of last Medical Exam?

Date of last Dental Appointment?

Yes No

Have you had problems with prior dental treatments?

Yes No

Are you in pain now?

II. Have You Experienced?

Yes No

Chest pain (angina)?

Yes No

Dizziness?

Yes No

Swollen ankles?

Yes No

Shortness of breath?

Yes No

Recent weight loss, fever, night sweats?

Yes No

Fainting spells?

Yes No

Persistent cough, coughing up blood?

Yes No

Seizures?

Yes No

Excessive thirst?

Yes No

Difficulty swallowing?

Yes No

Jaundice?

Yes No

Difficulty urinating, blood in urine?

III. Do You Have or have you had?

Yes No

Heart disease?

Yes No

AIDS or ARC?

Yes No

Heart attack, heart defect?

Yes No

Tumors, cancer?

Yes No

Heart murmurs?

Yes No

Arthritis, rheumatism?

Yes No

Heart surgery?

Yes No

Eye disease?

Yes No

Heart valve disorder?

Yes No

Pacemaker?

Yes No

Heart valve replacement?

Yes No

Anemia?

Yes No

Rheumatic heart disease?

Yes No

VD (syphilis or gonorrhea)?

Yes No

High blood pressure?

Yes No

Herpes?

Yes No

Stroke, hardening of arteries?

Yes No

Kidney, bladder disease?

Yes No

Hepatitis, other liver disease?

Yes No

Thyroid, adrenal disease?

Yes No

Radiation treatments?

Yes No

Diabetes?

Yes No

Family history of diabetes, heart problems, tumors?

Yes No

Allergies to drugs food, medications?

Please list

Yes No

Chemotherapy?

Yes No

Artificial joint?

IV. Are You Taking?

Yes No

Drugs, medicines, (including Aspirin)?

Please list:

V. Women Only:

Yes No

Are you or could you be pregant or nursing?

Yes No

Taking birth control pills?

VI. All Patients:

Yes No

Do you have or have you had other diseases or medical problems NOT listed on this form?

If so, please explain:

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my nealth and/or medication.

Patient Signature Date