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Download Medical History - Nigel Morgan, DDS
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Transcript
Nigel R. Morgan, DDS 420 Fifth Avenue West, Suite 200 Hendersonville, N.C. 28739 (828) 693-3949 Patient Information Patient Name: _________________________________________________________ Date:_______________ Last Male First Female MI Married Single Child Other _____________ Social Security #: ________________________________ Birth Date:_________________________________ Phone (Home): ________________ (Work): ________________ Ext:______ Best time to call:_____________ Address: _______________________________________________ Email:______________________________ Street and Apartment # __________________________________________________________________________________ City State Zip Code Health Information Date of Last Dental Visit: __________________ Reason for this visit:___________________________________ Have your ever had any of the following? Please check those that apply: AIDS Fainting Mental Disorders Allergies __________ Glaucoma Nervous Disorders __________ Growths Osteoporosis Meds Anemia Hay Fever Pacemaker Pregnancy Arthritis Head Injuries Artificial Joints Heart Disease Due date:_________ Asthma Heart Murmur Radiation Treatment Blood Disease Hepatitis Respiratory Problems Cancer High Blood Pressure Rheumatic Fever Diabetes Jaundice Rheumatism Dizziness Kidney Disease Sinus Problems Epilepsy Latex Allergy Stomach Problems Excessive Bleeding Liver Disease Stroke Tuberculosis Tumors Ulcers Venereal Disease Codeine Allergy Penicillin Allergy OTHER: _________________ ___________________ Have you ever had any complications following dental treatment? Yes No If yes, please explain: _______________________________________________________________________ Yes No Have you been admitted to a hospital or needed emergency care during the past two years? If yes, please explain:______________________________________________________________________ Are you now under the care of a physician? Yes No If yes, please explain:______________________________________________________________________ Name of Physician: _______________________________________________ Phone:___________________ Please list your medications if applicable: ________________________________________________________________________________________ To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the staff at the next appointment without fail. _________________________________________________________________ Date:___________________ Signature of patient, parent or guardian Referral Information Whom may we thank for referring you to our practice? Dental Office Yellow Pages Newspaper Name of person or office referring you to our practice: Another patient, friend School Work Another patient, relative Other__________________ __________________________________________
