riperiodontics.com-Med-Hx6

RHODE ISLAND PERIODONTICS

Health History
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email*
example@example.com
Today's Date*

MonthDayYear
Please check off any medical conditions that may appIy to you:*

ArthritisAnemiaBlood DiseaseBleeding DisorderImmunosupressionCancerAFIBBacterial EndocarditisHIGH Blood PressureLOW Blood PressureHeart DiseaseRheumatic FeverHIGH CholesterolMitralValve ProlapsePacemakerHeart MurmurCardiac ShuntCardiac StentStrokeTIAHeart Valve ReplacementDiabetesDry MouthEpilepsy /SeizuresHIV/AIDSJoint ReplacementKidney DiseaseLiver DiseaseHepatitisAspirin useNarcotic AddictionAsthmaAnxietyDepressionDiabetesRespirator DisorderOsteoporosisSteroid useStomach DisorderTuberculosisThyroid DisorderUlcersRadiation TherapySinus DisorderNone
Please clarify or list an additional medical conditions that you may have:
Are you taking any medications?*

YesNo

Allergies:*

Allergy to AntibioticAllergy to NarcoticsAllergy to NSAIDSAllergy to LatexAllergy to PenicillinAllergy local anestheticNo allergiesOther
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 NameLast Name
Phone *

Area CodePhone Number
Physician(s) Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Name*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / 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*

MonthDayYear
Relationship if not patient
Witness

Clear
Date

MonthDayYear
Should be Empty:

	Medication	Reason
1
2
3
4
5