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Michael G. Crookston, DDS • Nathan D. Call, DDS 1 Please Read , and Answer the Fol owing Questions, Medical History Form
Are you having pain or discomfort at this time? 2. Do you have or have you ever had bleeding or sensitive gums? 3. Do you feel nervous about having dental treatment? 4. Have you been hospitalized during the past two years? 5. Have you been under the care of a medical doctor during the past two years? Physician’s Name__________________________________________________________Type of Practice_____________________ Address_________________________________________________________________ Phone___________________________ Have you taken any medication or drugs during the past two years? 7. Are you now taking any medication, drugs or pills? If yes, please list:___________________________________________________________________________________________ 8. Are you allergic or have you reacted adversely to any of the following? 9. Check any of the following, which you HAVE HAD OR HAVE at present: 10. When you walk up stairs or take a walk, do you ever have to stop because of pain in the chest, shortness of breath, or because you are very tired?
11. Do your ankles swell during the day?
12. Do you use more than 2 pillows to sleep?
13. Are you on a special diet? If so, please explain____________________________________________________________
14. Have you ever taken Phen-Fen or similar appetite suppressants? If Yes, have you seen your physician or cardiologist for a cardiac evaluation?
15. Do you have any disease, condition, or problem not listed?___________________________________________________________
16. Have you visited a dentist in the past year? Date of last dental visit_____________________________________________________
17. FOR WOMEN ONLY: ARE YOU PREGNANT? If yes, what month?____________________________________________________
18. FOR WOMEN ONLY: Are you taking birth control pills? 2 Please Read, Health Questionnaire and Acknowledgement with Consent to Proceed:
I certify that the answers to the health questions are accurate and correct to the best of my knowledge. Since a change of medical condition or medications can affect dental treatment, I understand the importance of and agree to notify the dentist of any changes at any subsequent appointment. I authorize Dr. Michael G. Crookston and/or Dr. Nathan D. Call and/or such associates or assistants as he may designate, to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and / or administration of any sedative (including nitrous oxide), analgesic, other pharmaceutical agent (s), including those related to restorative, palliative, therapeutic or surgical treatments. I understand that the administration of local anesthetic may cause an untoward reaction or side effects which may include but are not limited to, bruising, hematoma, cardiac stimulation, temporary or rarely, permanent numbness, and muscle soreness. I understand that occasionally needles break and may require surgical retrieval. I understand that as part of dental treatment, including preventive procedures such as cleanings and basic dentistry, including fillings of all types, teeth may remain sensitive or possibly quite painful both during and after completion of treatment. Gums and surrounding tissues may also be sensitive or painful during and / or after treatment. I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventive and operative treatment procedures in hopes of obtaining and potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me as necessary and I have been given the opportunity to ask questions. 3 Please Sign Below
Signature of Patient, Parent or Guardian 4 Review of Medical History
I have reviewed the forgoing Medical History (other side) and find it to be unchanged and accurate, except as noted Signature of Patient, Parent or Guardian Signature of Patient, Parent or Guardian Signature of Patient, Parent or Guardian

Source: http://royfamilydental.biz/sites/royfamilydental/docs/Medical_History_Form_PDF.pdf

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