riperiodontics.com-Med-Hx6

RHODE ISLAND PERIODONTICS

Health History
Name *

First Name Last Name
Date of Birth *

Month Day Year
Email *
example@example.com
Today's Date *

Month Day Year
Please check off any medical conditions that may appIy to you: *

Arthritis Anemia Blood Disease Bleeding Disorder Immunosupression Cancer AFIB Bacterial Endocarditis HIGH Blood Pressure LOW Blood Pressure Heart Disease Rheumatic Fever HIGH Cholesterol MitralValve Prolapse Pacemaker Heart Murmur Cardiac Shunt Cardiac Stent Stroke TIA Heart Valve Replacement Diabetes Dry Mouth Epilepsy /Seizures HIV/AIDS Joint Replacement Kidney Disease Liver Disease Hepatitis Aspirin use Narcotic Addiction Asthma Anxiety Depression Diabetes Respirator Disorder Osteoporosis Steroid use Stomach Disorder Tuberculosis Thyroid Disorder Ulcers Radiation Therapy Sinus Disorder None
Please clarify or list an additional medical conditions that you may have:
Are you taking any medications? *

Yes No

Allergies: *

Allergy to Antibiotic Allergy to Narcotics Allergy to NSAIDS Allergy to Latex Allergy to Penicillin Allergy local anesthetic No allergies
Please list any other allergies that you may have:
Have you had any recent surgeries, hospitalizations, or major illnesses?
Do you require premedication with antibiotics prior to dental therapy for a heart condition or artificial joint replacement? If yes, what for and what antibiotic?
Have you EVER been treated with oral or intravenous medication for osteoporosis? If so, what medication(Ex:Actonel, Aredia, Boniva, Didronel, Fosamax, Reclast, Skelid, Zometa, etc.) and for how long?
Tobacco Use/History:

Women ONLY:

	Yes	No
Pregnant
Menopause
Taking Birth Control
Hormone Therapy

Emergency Contact:
Relationship to Patient *
Name *

First Name Last Name
Phone *

Area Code Phone Number
Physician(s) Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Pharmacy Name *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Other Notes:
General Consent to Treatment:

I agree and consent to a dental examination and understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatment performed.

Release of Information:

I authorize Dr. Katz, Theberge, Coleman and Pham to release any information regarding my dental/medical history, diagnosis or treatment to third party payers and/or other health professionals.

Acknowledgement of Receipt of Notice of Privacy:

I have received a copy of this office's Notice of Privacy Practices

Authorization must be signed by the patient, or by the nearest relative in the case of a minor or when the patient is physically or mentally incapable.

I hereby state that the above health questionnaire has been answered to the best of my knowledge.

I authorize the release of information.

I understand and agree to the General Consent to Treatment.

I acknowledge receipt of notice of privacy.
Signature *

Clear
Date *

Month Day Year
Relationship if not patient
Witness

Clear
Date

Month Day Year
Should be Empty:

	Medication	Reason
1
2
3
4
5