Completedentalhealth.net

619.295.2202 • www.completedentalhealth.com Accurate answers wil help us provide you the safest treatment experience. Al information you provide is confidential. If you need assistance or have a question, please ask.
Patient’s Name _____________________________________________________________________________________ ____________ Your PHYSICIAN’S name and phone #Yes ❏ No ❏ Have you ever been hospitalized or had surgery? If yes, please give year and reasons or types of operations.
Please mark YES or NO and CIRCLE any specific condition you currently have or have had previously.
MEDICATIONS Have you ever taken any of the fol owing: Please list al prescription and over-the-counter medications you are currently taking ___________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ blood disorder, blood transfusion, sickle cel congenital heart defects, artificial valves, endocarditis past or present drug use including cocaine, difficulty breathing at night, snoring, sleep apnea do you participate in any sports __________________ _________________________________________ Do you have any of the fol owing al ergies: local anesthetics (novocaine, lidocaine, etc.) aspirin, codeine, or other pain medication hives, contact dermatitis, latex sensitivity al ergic to any other medication ___________________ problem not listed above? _______________________ __________________________________________ any complication with / reaction to past how nervous does dental treatment make you: any injury to your teeth, mouth, jaws, or head ____ not at al ____ slightly ____ moderately ____ extremely Reason for today’s visit __________________________________ any awareness of clenching or grinding your teeth _______________________________________________________ How do you feel about the appearance of your front teeth _______________________________________________________ _______________________________________________________ _______________________________________________________ Previous dentists name _________________________________ City __________________________________________________ Date of last dental treatment _______________ treatment. If yes, describe _____________________ _________________________________________ To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be very dangerous to my health. I also understand it is very important to report any changes in my medical or dental status to the dentist at the earliest time, and I agree to do so.
AUTHORIZATION FOR USE OF IMAGE AND BIOGRAPHICAL INFORMATION I am a patient of Dr. . I understand that my dentist may take video or still images of the work that he is doing. I consent to my dentist, or a representative of his staff, taking these images. I understand that my dentist may use my images, and biographical information that I provide to my dentist, for purposes of education, publicity, promotion and advertising. I understand that I will receive no remuneration for such use.

Source: http://www.completedentalhealth.net/patient-resources/forms/health-history.pdf