Download Health History - Bluegrass Endodontics

Date: _________________________
Patient information
Patient Name: _________________________________________ DOB: ___________________
Patient SSN:_____________________
Patient Address: ________________________________________________________________________
Home phone: ______________________________________________
Employer:_______________________________________
Zip Code:_________________
Cell phone: _____________________________________________
Employer Phone Number: _______________________________________
Person Responsible (If different from patient): ___________________________________________ DOB:_______________
Dentist: ______________________________________
Family Physician: __________________________________
Emergency contact:_______________________ Phone number:______________________ Relation:__________________________
Insurance
Dental Insurance: ___________________________ ________
Sub Date of Birth: ______________
Primary Subscriber: _________________________________
Sub SSN #: ____________________________
Ins Phone: ______________________________
Health History
Have you or a family member been here before? __________________Name? ___________________________
Chief Complaint for today’s appointment: ________________________________________________
Is the present problem due to an accident: _________________ Last Physical: ________________
Have there been any changes in your medical history or serious illness in the last year: _______________
Pharmacy Name: ______________________________
Pharmacy Location: ________________________
Do you have (circle all that apply): Anemia, Rheumatic fever, Rheumatic heart disease, Mitral valve prolepses,
Congenital heart lesions, Cardiovascular disease, Allergy, Asthma, Hay fever, Hives, Skin rash, Fainting spells,
Seizures, Diabetes, Hepatitis, Jaundice, Liver disease, Arthritis, Inflammatory rheumatism, Stomach ulcers, Kidney
trouble, Tuberculosis, Low blood pressure, High blood pressure, Venereal disease, HIV or Aids, OTHER:
__________________________________________________________________________________________________
Do you have a blood or clotting disorder?:____________________________________________________________________
Are you taking any medication if so please list: ____________________________________________________________
Allergy to any medications?: ___________________________________________________________________________________________
Have you ever had any complications associated with previous dental treatment if so explain:
__________________________________________________________________________________________________________________
Women: Are you pregnant: ______________
_____________ I understand that I need to follow up with my general dentist after the completion of my root
canal for permanent restoration. Please initial as acknowledgement.
I hereby grant authority to Bluegrass Endodontic to perform treatment procedure, including the administration of
anesthetics and medication, he/she deems necessary for the care of the patient named above. I have read and
understand the patient information sheet provided.
__________________________________________________
Signature of Patient/Guardian
__________________________________________________
Signature of Doctor
________________________
Date