Macoupin County Maple Street Dental Clinic HEALTH HISTORY Patient’s Name_________________________________________ Today’s Date_______________________ Street Address_________________________________________ Birthdate__________________________ City__________________ State________ Zip_____________ Sex (circle) M / F Date of last dental exam___________________ Phone number ( ) Work/other number ( )_______________________________ Physician’s Name__________________________ Address________________________________________ Please answer all questions by circling Yes (Y) or No (N). All responses are kept confidential. 1. Has there been any change in your 6. Are you allergic or had an adverse reaction to: 2. Have you ever had any illness, operations,
If yes, please describe_________________________
_____________________________________________ _____________________________________________ _____________________________________________
h. Please list any other allergies/reactions.
_____________________________________________
3. Are you being treated by a physician
_____________________________________________
_____________________________________________
7. Are you using any of the following: 5. Do you currently have or have ever had:
a. Rheumatic fever/rheumatic heart disease? Y N Circle all that apply: heart disease,
heart murmur, heart attack, coronary artery
disease, angina, high blood pressure, stroke,
i. Oral bisphosphates (bone hardening meds)? Y N
j. IV bisphosphates (bone hardening meds)?
Circle all that apply: asthma, tuberculosis, chest
pain, severe coughing, bronchitis, pneumonia
e. Seizures, epilepsy, fainting, dizziness?
8. Do you smoke or chew tobacco?
g. Liver disease (jaundice, Hepatitis)?
9. Do you have a past history of alcohol
or chemical dependency? 10. Have you had any serious problems
Glaucoma? Y N 11. Please list current medications. Include prescriptions, over-the-counter, vitamins, and herbal 12. For Women Only remedies. Medication
Due Date______________________ _____________________________________________ _____________________________________________ If you are using oral contraceptives, it is important that you understand that antibiotics and some other medications may _____________________________________________
interfere with the effectiveness of oral contraceptives.
_____________________________________________
Therefore, you will need to use mechanical forms of birth
_____________________________________________
control for one complete cycle of birth control pills after the
_____________________________________________
course of antibiotics or other medication is completed. Please
_____________________________________________
consult with your physician for further guidance.
_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Please list any medical or dental problems or concerns that were not covered in above questions. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ I understand the importance of a truthful health history to assist the dental staff in providing the best care possible. I have had the opportunity to discuss my health history with my doctor. Date___________ Patient/Guardian Signature__________________________ Dentist’s initials__________ Medical Update: I have read and updated my health history dated_________________ and confirm that
it adequately states past and present conditions. Date___________ Exceptions/changes________________________________________________ ___________________________________Signature Date_____________ Date___________ Exceptions/changes________________________________________________ ___________________________________Signature Date_____________ Date___________ Exceptions/changes________________________________________________
__________________________________ Signature and Date___________ Revised 11/2011
Journal of Orthodontics, Vol. 34, 2007, 000–000supernumerary: a complication ofspace closureA. ShahLiverpool Road Health Centre, Luton, UKS. HiraniLuton and Dunstable Hospital, Luton, UKThis case report describes a situation in which a mandibular supernumerary developed during orthodontic treatment andprevented space closure. Key words: Late forming supernumerary, space closure complication
Mt. Calvary-Grace Lutheran School 1614 Park Avenue La Crosse, WI 54601-5796 A member of the Wisconsin Evangelical Lutheran Synod “Be strong in the Lord and in his mighty power.” Ephesians 6:10 Permission to Treat To be presented to the Emergency Department Full Legal Name (first, middle, last) _________________________________________________ Date of Birth ______________________