MEDICAL HISTORY
1.Are you in good health?_______________________________________
2.Are you under a physician’s care now? _________________ If so, please give reason
for treatment.________________________________________________________________
3.Are you taking any kind of medication at this time?__________________________________
4.Have you ever taken Fen-Phen/Redux?_________________________________
5.Please circle any illnesses you have ever had:
allergies tuberculosis anemia kidney or liver other
rheumatic fever diabetes heart trouble asthma
infectious hepatitis epilepsy glaucoma HIV infection
6.Do you have a persistent cough or throat clearing not associated with a known illness
(lasting more than 3 weeks)?_____________________________________________________
7.Have you ever had trouble with prolonged bleeding after surgery?_____________________
8.Have you ever had any unusual reaction to an anesthetic or drug (like penicillin)?__________
9.Is there any other information that should be known:
about your health?_____________________________________________________________
about previous dental visits?______________________________________________________
Signature: __________________________________________
REGISTRATION
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mr. mrs. miss Date Date of birth s m w d |
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HOME ADDRESS HOME PHONE |
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CITY STATE ZIP CODE |
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E-MAIL CELL PHONE SS#/SIN - - |
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EMPLOYER ADDRESS |
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OCCUPATION BUS. |
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PREVIOUS ADDRESS TEL. |
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PERSON RESPONSIBLE FOR ACCOUNT CITY STATE |
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ADDRESS |
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REFERRED BY PHYSICIAN |
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DENTAL INSURANCE PROGRAM LOCAL NO. |
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PURPOSE OF CALL |
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PREFERRED DAY FOR APPTS. TIME AM or PM |
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REMARKS |
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