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Dr. bruno paliani - new patient package

Name : _________________________________________ MEDICAL HISTORY
Are you presently being treated for any medical condition? If yes, please explain ______________________________________________________
Are you presently under the care of a physician ? If yes, please explain ______________________________________________________________
Have you had a medical examination in the last year ? For ? _______________________________________________________________________
When was your last complete physical? _____________________ New findings? ______________________________________________________
Has there been any change in your general health in the past year? If yes, please explain _________________________________________________
Have you ever been tested positive for any immunocompromising disease? If yes, please explain __________________________________________
Is there any other medical condition, adverse reaction, disease or problem not listed above? If yes, please explain _____________________________
Have you ever been hospitalized for any serious illness, operations, or conditions requiring extensive medical care?___________________________
Have you ever been advised by your doctor(s) to take antibiotics before dental treatment?________________________________________________
Do you have or have you ever had any of the following ? (If yes, please circle)
Heart
Circulatory System
- Heart condition/problem - bleeding problem/disorder heart surgery/valve surgery - Sickle Cell Anemia - seizures prosthetic heart valve - Hemophilia - dizzy spells - Leukemia - fainting spells - frequent ear aches Liver and Kidney
Face/Jaw/Teeth
- warned against giving blood - bladder problems - extra pillows to sleep or recline - give blood regularly Lungs/Respiratory Head and Neck
Infectious Diseases
Neuro/Muscular/Skeletal
Digestive System
Family History of…
Operations/Surgery
- other operations requiring hospitalization ________________ Women Only
Social History
lost 10 lbs. in last year Eating Disorders
Allergies, Adverse Reactions or Hypersensitivities
Taking the Following Medications
Dental History
- OTHER drugs/medicine/injections__________________________
- latex/rubber ____________________________________________ - Environmental allergies ___________________________________ - other prescription drugs________________________________ metal allergies (ie jewelry) ________________________________ - other over-the-counter (non-prescription) drugs _____________ - Herbal Supplements ___________________________________ - OTHER_____________________________________________
Foods ________________________________________________ Hives, Rashes _________________________________________ Family Physician
Specialists
Specialty:
Current Medications Used
Present Medical Condition
(Existing Illnesses)
Name of Drug
Daily Schedule
Comments
I have reviewed the medical history on the previous page and have noted any changes. I have also updated theinformation above in regards to my present medical condition and current medications being used. To the bestof my knowledge, I believe this information to be accurate and true and have not knowingly omitted anyinformation. In addition, I give my permission for Dr. Paliani and his staff to communicate with any otherhealthcare provider in regards to my medical and dental treatment.
Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________Date:__________________ Signature:________________________________ Staff/DDS Initials:________ F:\docs\Office manual - Revised - 2001-05-17\Chart Maintenance\Patient Information Forms\MEDICAL HISTORY.doc

Source: http://www.smiledentist.ca/pdf/NewPatientForms/MedicalHistory.pdf

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