Cbd medical hist form

PATIENT MEDICAL FORM
Family Name:__________________________________ First Name:_____________________________ Date of Birth: (year/Month/Day) _______/_____/_____ Sex: (circle) Male / Female Home address: ________________________________ Home Phone: ___________________________ Email: ________________________________________ Work / Cell Phone: _______________________ Medical History: (please check yes or no Box below)
Yes No
❑ ❑ Have you had a medical checkup within the last year? If not, indicate year of last check up: __________________
❑ ❑ Have you ever had any general surgery? If so, explain: ___________________________________________________
❑ ❑ Have you been treated for any medical conditions within the last year? If so, explain:_________________________
____________________________________________________________________________________________________________
❑ ❑ Have you taken any medicine or drugs within the past month? If so, list:
❑ ❑ Have you ever been told by a physician (family doctor) that you require antibiotics before dental treatment for
a medical condition or any reason? ____________________________________________________________________
❑ ❑ Do you have andy conditions or therapies that could affect your immune system, such as Leukemia?__________
❑ ❑ Have you ever taken a Bisphosphonate medication such as Actonel (Risedronate), Aredia (Pamidronate),
Benefos (Clodronate), Boniva (Ibandronate), Didronel (Etidronate) Fosamax (Alendronate), or Zometa (Zoledronic Acid)
for any reason, such as during the treatment of Paget’s Disease, Osteoporosis, osteogenesis Imperfecta, Multiple
Myeloma, or Metastatic Bone Disease from Breast or Prostrate Cancer?
❑ ❑ Have you taken Cocaine, Ecstasy or Methamphetamine within the last 24 hours?
❑ ❑ Are you allergic to any medicine of drugs such as Local Anaesthetic given by a dentist, Penicillin, Codeine, or
Aspirin? If so, list: ___________________________________________________________________________________________
❑ ❑ Are you allergic to latex or rubber?
❑ ❑ Do you have any other allergies? If so, list:______________________________________________________________
❑ ❑ Do you smoke or chew tobacco products? If so how often? _______________________________________________
❑ ❑ Women Only - Are you nursing (breastfeeding) of pregnant? If pregnant, how many months: __________________
Do you have or have you ever had any of the following: (please check yes or no box below:
Yes No !
❑ ❑ Chest Pain (angina pectoris) ❑ ❑ Anemia ❑ ❑ Arthritis ❑ ❑ Heart Attack ❑ ❑ High Blood Pressure ❑ ❑ Stomach Ulcers ❑ ❑ Pacemaker ❑ ❑ Bleeding Problems/Disorder ❑ ❑ Sinus Trouble ❑ ❑ Infective Endocardiditis ❑ ❑ Stroke ❑ ❑ Asthma ❑ ❑ Congenital Heart Disease ❑ ❑ Kidney Trouble ❑ ❑ Steroid Therapy ❑ ❑ Prosthetic. Artificial Heart Valves ❑ ❑ Do you have any other serious illness? If so, explain: _____________________________________________________ Name of your physician (family doctor): ______________________________________ Phone: __________________________ When was the last time you saw a dentist? _____________________________________________________________________ The above medical history is complete and accurate. Consent for treatment is hereby given.
_______________________________________ ____________________________________
Signature of Patient / Parent / Guardian Date

Source: http://crystalbeachdental.ca/wp-content/uploads/2013/03/CBD-Medical-Hist-Form.pdf