PATIENT MEDICAL HISTORY UPDATE
Patient Name
Date of Birth
All information provided here is 100% confidential and any attempt to conceal preexisting conditions or other relevant information could result in serious patient drug interactions or death. The following questions must be answered honestly so that our office can provide you with the best possible care.
Please check the correct response :
1. Have you ever been seriously ill since your last office visit?
Yes
No
2. Have there been any changes in your medical history since your last office visit?
Yes
No
If yes, please explain:
3. Is a medical doctor currently treating you?
Yes
No
4. Primary care physician’s name:
Primary care physician’s phone number:
5. Please list any medication (Prescription or Over-the-Counter):
6. Are you allergic to, or have you had unusual reactions to any of the following?
Aspirin
Yes
No
Erythromycin
Yes
No
No Known Allergies
Yes
No
Barbiturates
Yes
No
Iodine
Yes
No
Penicillin
Yes
No
Codeine
Yes
No
Latex
Yes
No
Sulfa Drugs
Yes
No
7. Please check the box if you have ever been told you have any of the following:
Heart Defect
Yes
No
Anemia
Yes
No
Jaundice
Yes
No
Infective Endocarditis
Yes
No
Depression
Yes
No
Frequent Headaches
Yes
No
High Blood Pressure
Yes
No
Sinus Trouble
Yes
No
Asthma
Yes
No
Low Blood Pressure
Yes
No
Rheumatic Fever
Yes
No
Hay Fever
Yes
No
Diabetes
Yes
No
Hepatitis
Yes
No
Kidney Disease
Yes
No
ADHD / ADD
Yes
No
Tuberculosis
Yes
No
Swollen Neck Glands
Yes
No
Hives / Skin Rash
Yes
No
Active Infection
Yes
No
Thyroid Problems
Yes
No
Epilepsy
Yes
No
Autism
Yes
No
Other
Yes
No
Seizures
Yes
No
Stroke
Yes
No
OTHER
I have read and understand the above questions. I have answered all of these questions truthfully to the best of my ability and knowledge. I consent to the diagnostic procedures and dentistry necessary for proper dental care.
By providing a mobile number, I agree that Carolina Orthodontics & Children’s Dentistry may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.
SIGNATURE X
Submit
