Health History Form - Foundation Implants

Email Address *

Date *

AS REQUIRED BY LAW, OUR OFFICE ADHERES TO WRITTEN POLICIES AND PROCEDURES TO PROTECT THE PRIVACY OF INFORMATION ABOUT YOU THAT WE CREATE, RECEIVE OR MAINTAIN. YOUR ANSWERS ARE FOR OUR RECORDS ONLY AND WILL BE KEPT CONFIDENTIAL SUBJECT TO APPLICABLE LAWS. PLEASE NOTE THAT YOU WILL BE ASKED SOME QUESTIONS ABOUT YOUR RESPONSES TO THIS QUESTIONNAIRE AND THERE MAY BE ADDITIONAL QUESTIONS CONCERNING YOUR HEALTH. THIS INFORMATION IS VITAL TO ALLOW US TO PROVIDE APPROPRIATE CARE FOR YOU. THIS OFFICE DOES NOT USE THIS INFORMATION TO DISCRIMINATE.

First Name *

Middle Name *

Last Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Cell Phone *

Date Of Birth *

Sex *MaleFemaleOther

Emergency Contact *

Relationship *

Dental Information (For the following questions, please mark (X) your responses to the following questions)

Date of your last dental exam *

Medical Information (Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems)

Are you now under the care of a physician? *YesNoDK

Have you had a serious illness, operation or been hospitalized in the past 5 years? *YesNoDK

If yes, what was the illness or problem? *

Physician Name: *

Physician Phone *

List any Medicine or supplement you are taking *

Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? *YesNoDK

Joint Replacement's Date *

If yes, have you had any complications? *

ARE YOU TAKING OR SCHEDULED TO BEGIN TAKING any bisphosphonate medications like, risedronate (Actonel), alendronate (Fosamax), ibandronate (Boniva), zoledronic acid (Reclast), and pamidronate (Aredia) *YesNoDK

WOMEN ONLY

Are you Pregnant?YesNoDk

Number of Weeks:

List any Allergies *

Do you have any disease, condition, or problem not listed above that you think I should know about? *YesNoDk

Please explain: *

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Signature of Patient/Legal Guardian *

Date *

For Completion By Dentist *

Comments *

Ensuring Comprehensive Care Through Detailed Medical Information

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