Download dental patient medical history - Santa Ynez Tribal Health Clinic

DENTAL PATIENT MEDICAL HISTORY
Santa Ynez Tribal Health Clinic
Please answer all of the following questions. If you are unsure how to
answer any question(s), please ask the front office staff for assistance.
Patient Name:
Chart #:
DOB:
What is the name of your medical doctor?
Please list medications you are taking?
Are you allergic to any medications?
PLEASE CHECK:
1.
2.
3.
4.
5.
6.
Are
Are
Are
Are
Are
Are
you
you
you
you
you
you
Y
N
taking any blood thinners?
taking any blood pressure medication?
taking any heart medication?
taking any calcium replacements?
taking any other kind of medication?
allergic to latex?
Do you currently have, or have you ever had, any of the following?
PLEASE CHECK:
1. Heart attack
2. Heart murmur
3. Heart valve/pace maker
4. Heart stent
5. Any heart condition
6. Artificial joint/replacement
7. Stroke
8. High blood pressure
9. Rheumatic fever
10. Epilepsy/seizures
11. Blood transfusion
12. Cancer/Tumors
13. Reaction to anesthesia
14. Bleeding disorders
15. Diabetes
FEMALE PATIENTS ONLY:
Are you currently:
Y
1. Are you pregnant?
2. Taking birth control pills?
3. Nursing?
STAFF USE ONLY
Place stamp here
Y
N
PLEASE CHECK:
16. Hepatitis
17. HIV/Aids
18. STD’s
19. Liver problems
20. Kidney problems
21. Asthma
22. Sinus problem
23. Nervous/Mental Disorder
24. Anemia
25. Ulcers
26. TB Lung Disease
27. Use Drugs
28. Use Alcohol
29. Use Tobacco
If so, want to quit?
Y
N
ALL PATIENTS:
Do you have any other conditions, problems no listed?
If yes, please specify:
Do you have any concerns about receiving dental treatment?
If yes, please specify:
The answers I have given are true to the best of my
knowledge. I am indicating my consent for routine dental
procedures such as x-rays, cleaning, fillings, crowns, and local
anesthesia by signing below.
Patient:
Provider:
Document1
N
SIGNATURES
Date:
Date:
rev0915