New Medical History Palermo
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Relation
Emergency Phone #
INSURANCE INFORMATION
Your coverage details. Please review them and make any necessary adjustments.
Primary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
Secondary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
Medical History
Please answer all questions to the best of your knowledge
Are you presently under medical treatment?
Yes
No
Reason for medical treatment:
Name and phone number of Physician(s)
Are you presently taking any medication?
Yes
No
If so, which medications?
Have you ever been hospitalized for any illness or operations
Yes
No
If so, please specify when and what illness or operation
Do you have any drug, food or metal allergies?
Yes
No
If so, please specify.
Have you ever been treated for or do you have any of the following:
Diabetes
Hepatitis
Heart Condition/Chest Pain/Heart Attack
Epilepsy
Asthma/Lung Disease/Emphysema
High Blood Pressure
H.I.V.
Allergies
Contagious Disease
Thyroid
Cancer/Radiation Therapy
Repeated Headaches
Artificial Joints
Emotional or Nerv. Disorders
Stroke
Low Blood Pressure
Organ Transplants
Alcohol Dependency
Drug Dependency
Sickle Cell Disease
TB (Tuberculosis)
Malignant Hyperthermia
Liver Disease
Kidney Disease
Stomach Ulcers/Digestive Disorders
Arthritis
Head or Neck Injuries
Osteoporosis/Osteopenia
Viral Infections or Cold Sores
Pacemaker/Artificial Heart Valve
I Do Not Have Any of the Above
Other (specify) or Details of Above Questions
Do you bleed for prolonged periods or bruise easily?
Yes
No
If so, please specify.
Females: Are you pregnant or taking birth control pills? Due date.
Do you smoke?
Yes
No
Have you gained weight recently?
Yes
No
If so, how much and why?
Have you lost weight recently?
Yes
No
Are you presently on any special diets?
Yes
No
If so, how much and why?
Do you clench or grind your teeth or find that you have a sore jaw in the morning?
Yes
No
Don't Know
Do your gums bleed frequently when brushing or flossing?
Yes
No
Don't Know
Do you freqently have a bad taste in your mouth or bad breath?
Yes
No
Are your teeth sensitive to hot, cold or sweets?
Yes
No
Have you ever had braces?
Yes
No
When you smile or laugh do your teeth have visible chips, gaps, cracks or dark fillings?
Yes
No
Are you interested in making your teeth whiter?
Yes
No
Check any of the following that you would like to know more about.
White Fillings
Veneers/Crowns (Caps)
Dental Implants
Tooth Whitening
Snoring Appliances
Ceramic Fillings and Crowns (CEREC)
Medical History Updates
Specify:
Notes
Obstructive Sleep Apnea and Snoring
Obstructive sleep apnea (OSA) is a common but serious medical condition that can affect your sleep, health and quality of life. If left untreated, OSA sufferers are at higher medical risk for many conditions including, but not limited to,
heart attacks, strokes, and sleepiness that can lead to work related accidents and car crashes.
OSA IS DANGEROUS! IT'S IMPORTANT TO TREAT OSA IF YOU HAVE IT!
Do you have sleep apnea?
Yes
No
When were you diagnosed?
Do you have a CPAP or oral appliance to use when you sleep?
CPAP
Oral Appliance
Night Guard
None
Do you use your CPAP or oral appliance routinely?
Yes
No
Are you satisfied with your CPAP or oral appliance?
Yes
No
If you answered no to any of the two previous questions, why?
Do you or your spouse/partner snore loudly
Yes, I do.
Yes, my spouse/partner does.
Please answer the following questions to find out if you are at risk. Your health is important to us!
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? S
Yes
No
Do you often feel tired or sleepy during the day? T
Yes
No
Has anyone observed you stop breathing or gasp during sleep? O
Yes
No
Have you had or are you currently being treated for high blood pressure? P
Yes
No
Is your BMI (Body Mass Index) greater than 35? B
Yes
No
I don't know
Are you over 50 years old? A
Yes
No
Is your neck size greater than 17" (male) 16" (female)? N
Yes
No
Are you male? G
Yes
No
Patient Consent
I, the undersigned, certify that I have provided a complete and accurate personal and medical-dental history and have not knowingly omitted any information. I have the oppurtunity to ask questions and recieve answers to any questions above. I authorize the dentist to perform diagnostic procedures necessary to determine required treatment. I understand that the information may be required to be provided from or to other health care providers and I consent to the release of this information. I understand that the treatment in part or in whole can be consented verbally and that I am able to ask questions about such treatment.
Patient Signature
Doctor's Signature
