Microsoft word - do not print-health history.doc
S. BRETT DELAWTER, DDS
1025 N. Brand Blvd., #210
Glendale, CA. 91202
(818) 242-1708
NAME:_____________________________________________________________________
ADDRESS:__________________________________________________________________
CITY:_________________________________STATE:___________ZIP:________________
OCCUPATION_________________________ EMPLOYER ___________________________
BIRTHDATE:__________________________ S.S. NUMBER_________________________
TELEPHONE: Home________________Business________________Cell________________
EMAIL______________________________________________________________________
EMERGENCY CONTACT AND NUMBER:_______________________________________
INSURANCE INFORMATION
PRIMARY INSURANCE CO. NAME & ADDRESS: ________________________________________
POLICY/ GROUP NUMBER: _____________________________________________________________
EMPLOYER NAME:________________________________ ADDRESS:__________________________
EMPLOYEE NAME:____________________________________________________________________
EMPLOYEE BIRTHDATE:___________________EMPLOYEE S.S. NUMBER: ___________________
SECONDARY INSURANCE CO. NAME & ADDRESS: _____________________________________
POLICY/GROUP NUMBER: _____________________________________________________________
EMPLOYER NAME:_________________________________ ADDRESS _________________________
EMPLOYEE NAME:____________________________________________________________________
EMPLOYEE BIRTHDATE:___________________EMPLOYEE S.S. NUMBER: ___________________
AUTHORIZATION
I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I
understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the
doctor to release all information necessary to secure the payment of benefits.
SIGNATURE:____________________________________________DATE:_________________________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SPOUSE / PARENT NAME:______________________________________________________________
ADDRESS:____________________________________________________________________________
EMPLOYER:___________________________________________________________________________ BIRTHDATE:___________________________________S.S. NUMBER___________________________ TELEPHONE: Home____________________Business___________________Cell___________________
How did you hear about us? _______________________________________________________________ Why did you leave your last dentist? ________________________________________________________________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MEDICAL HISTORY AND INFORMATION
Have you had:
Are you Allergic to:
Are you currently under the care of a physician?
Yes ( ) No ( ) If yes, Doctor Name__________________
If yes, please explain:______________________________
________________________________________________
High Blood Pressure
Please list all current medications (include dosage and
condition you are taking it for): ______________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Have you ever had an adverse reaction to an anesthetic?
Alcoholism Yes ( ) No ( ) If yes, what?________________________
Do you use tobacco products? Do you require Antibiotic pre-medication for dental work?
If yes, what?___________________________
Yes ( ) No ( ) If yes, what?_________________________
Female Patients:
Yes ( ) No ( )
Have you taken the medication
Bisphosphonate as treatment for osteoporosis?
Yes ( ) No ( ) Are you taking Birth Control Medication?
(Such as Actonel, Boniva, Didronel, Fosamax, Reclast, etc)
I hereby authorize the dental office to administer such medications and perform such diagnosis and therapeutic Procedures as may be necessary for proper dental care. The information on this page and the medical history are correct to the best of my knowledge. I certify to the above statements regarding my medical condition. Payment for all treatment and services rendered are my responsibility.
Patient Signature
If patient or child is under 18 or requires a guardian: ______________________________________________________________________________________
Parent/Guardian Signature
______________________________________________________________________________________
Reviewed by
Source: http://theglendaledentist.com/wp-content/uploads/2012/11/Health-History.pdf
NAME OF THE MEDICINAL PRODUCT Cefuroxime Axetil Actavis 250 mg film-coated tablets Cefuroxime Axetil Actavis 500 mg film-coated tablets 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each tablet contains 250 mg cefuroxime as cefuroxime axetil Each tablet contains 500 mg cefuroxime as cefuroxime axetil For a full list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM
Bodsworth NJ, Bloch M, McNulty AM, Denham I, Doong N, Trottier S, Adena M, Bonney M-A, Agnew J, and the Australo-Canadian FaST Study Group . 2-day versus 5-day famciclovir as treatment of recurrences of genital herpes – results of the FaST study. Sexual Health 2008; 5: 219-225. Bourne C, Edwards B, Shaw M, Gowers A, Rodgers C, Ferson M. Sexually transmissible infection testing guid