MEDICAL HISTORY and CONSENT
Name: ________________________________________________
Date: ____________________
Although dental personnel treat the area in and around your mouth, your mouth is a part of your entire body. Health
conditions or problems that you may have or had, or medications that you may be taking, could have an important
interrelationship with the treatment you will receive. Thank you for answering the following questions.
Allergies
Acrylics
Y
Anaphalaxis
Y
Latex
Y
Local Anesthetics
Y
Penicillin
Y
Metal
Y
Sulpha
Y
Other
Y
List other known allergies:
N
N
N
N
N
N
N
N
Gastrointestinal
Acid Reflux
GERD
Soft or Special Diet
Ulcers
Y
Y
Y
Y
N
N
N
N
Genitourinary
Frequent Urination
Kidney disease
Nocturia
Y
Y
Y
N
N
N
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Cardiovascular
Artificial Heart Valve
Coronary Artery Disease
Chest Pain or Angina
Congestive Heart Failure
Heart Attack
Heart Murmur
High Blood Pressure
High Cholesterol
Irregular Heart Beat
Low Blood Pressure
Mitral Valve Prolapse
Pacemaker
Tachycardia
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
Endocrine
Diabetes
Gout
Hormonal Change
Thyroid problems
Y
Y
Y
Y
N
N
N
N
Eyes, Ears, Nose and Throat
Change in Hearing
Y
Change in Vision
Y
Dysphagia
Y
Ear Pain
Y
Glaucoma
Y
Hay Fever
Y
Nasal Obstruction
Y
Nose Bleeding
Y
Sinus Problems
Y
Tonsillectomy
Y
Tinnitus
Y
N
N
N
N
N
N
N
N
N
N
N
General
Current weight: _________lbs
Height: _______ ft ______in
Cancer
Y
Fatigue/Tired
Y
General Weakness
Y
Headaches
Y
HIV/AIDS
Y
Knee/hip replacement
Y
Liver problems
Y
Recent Trauma or Injury Y
Rheumatic Fever
Y
Radiation Treatment
Y
Weight Change
Y
N
N
N
N
N
N
N
N
N
N
N
Hematological
Bleeding problems
Hepatitis
N
N
Y
Y
Oral
Bleeding gums
Y
Dry mouth
Y
Jaw problems (TMJ)?
Y
Clicking?
Y
Pain?
Y
Difficulty swallowing? Y
Difficulty chewing?
Y
Orthodontics/Invisalign Y
Periodontal Disease
Y
Teeth clenching
Y
Teeth grinding
Y
Tooth pain
Y
Wisdom teeth extraction Y
Do you wear removable teeth?
Y
Do you take or need
antibiotics before
dental procedures?
Y
Musculoskeletal
Back Pain
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Psychiatric
ADD/ADHD
Anxiety
Chemical Dependency
Depression
Eating disorders
Excessive Stress
Memory problems
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Respiratory
Asthma
Bronchitis
Breathing problems
Chest Pressure
Congestion
Dyspnea(shortness of breath)
Emphysema
Orthopnea
Pneumonia
Pulmonary Embolism
Tuberculosis
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Sleep
Daytime Sleepiness
Y N
Morning headaches
Y N
Obstructive Sleep Apnea Y N
Do you use a CPAP?
Y N
How often? __________________
Has anyone told you that
you snore?
Y N
N
N
N
CONFIDENTIAL
Lake Country Dental- Reg 08/14
Fibromyalgia
Joint Pain
Neurological
Alzheimer’s Disease
Dizziness
Fainting
Memory Loss
Multiple Sclerosis (MS)
Muscle Weakness
Seizures
Stroke
Tingling/Numbness
Trigeminal Neuralgia
Tremor
Social History
Do you smoke?
N Y
_____ packs a day
Do you use smokeless tobacco? Y N
Do you consume alcoholic beverages?
_____Drinks per day/week/month
MEDICAL HISTORY and CONSENT
Name: ________________________________________________
Date: ____________________
Do you use recreational drugs? Y N
List any medications you are taking:
Medication
Dosage/Freq.
List any surgeries or hospitalizations you have had:
Prescriber
Reason
Date(year)
Surgery
Surgeon
Reason
1._____________________________________________________________
_______________________________________________________________
2._____________________________________________________________
_______________________________________________________________
3._____________________________________________________________
_______________________________________________________________
4._____________________________________________________________
_______________________________________________________________
5._____________________________________________________________
_______________________________________________________________
6._____________________________________________________________
_______________________________________________________________
List and detail any medical condition or history not listed above:
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Primary Physician’s Name: __________________________________________ Physician’s phone #: ______________________
Are you under the care of other physicians? If so, please list:
Physician
Phone #
Reason
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Dr. Reginald S. Young, LTD to take
radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the
undersigned patient’s dental condition and needs. I authorize Dr. Reginald S. Young, LTD to perform any and all forms of treatment,
medication, and therapy that may be necessary and further consent that Dr. Reginald S. Young, LTD choose and employ such
assistance as deemed necessary. I understand that the use of local anesthetics agents embodies certain risk and consent to their use
as deemed appropriate by Dr. Reginald S. Young, LTD. To the best of my knowledge, the questions on this form have been accurately
answered. I understand that providing incorrect or incomplete information can be dangerous to my/ the patient’s health. It is my
responsibility to inform the dental office of any change in medical health or status.
FINANCIAL CONSENT: I understand that responsibility for payment of services provided in this office for myself and my
dependent(s) is mine, due and payable at the time services are rendered. I understand that I am responsible for any portion of fees
for services rendered not covered by my dental or medical insurance (if any). I further consent to and agree to pay a 2% finance
charge (24% annually) that will be applied to any balance over 60 days. I acknowledge that I am responsible for all fees necessary
to collect my account. I authorize Dr. Reginald S. Young, LTD and his staff to verify insurance coverage, if any, to submit claims
and provide my insurance company with information required for a claim, to assign benefits, and to handle any necessary claim
appeal(s).
Consent (adult):
Name of Patient _________________________________________
___________________________________________
Signature of Patient
Date __________________
Consent (for a minor child):
Name of Parent/Guardian ____________________________________
___________________________________________ Date __________________
Signature of Parent/Guardian
Notice of Privacy Practices (below)
Patient privacy is important to our practice. We are required by law to maintain the privacy of Protected Health Information (“PHI”) and to
provide individuals with notice of our legal duties and privacy practices with respect to PHI. By signing below you are acknowledging
receiving notice of our practices’ policies and your rights regarding PHI. I allow release of pertinent medical records to my insurance company
(if applicable) and my other medical providers.
CONFIDENTIAL
Lake
Country Dental- Reg 08/14
___________________________________________
Signature of Patient
Date __________________