Confidential Health History & Acknowledgement of Receipt

Patient Name

Date of Birth

SELECT APPROPRIATE ANSWER (Leave blank if you do not understand the question)

1. Is your general health good?

Yes No

If No, Please explain

2. Has there been a charge in your health within the last year?

Yes No

If yes, Please explain

3. Have you gone to the hospital or emergency room or had a serious illness in the last three years?

Yes No

If yes, Please explain

4. Are you being treated by a physician now?

Yes No

If yes, Please explain

Date of last medical exam?

Reason for Exam?

5. Have you had problems with prior dental treatment?

Yes No

If yes, Please explain

Date of last medical exam?

Name of last treating dentist?

6. Are you in pain now?

Yes No

If yes, Please explain

Other

IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?

Aspirin

Penicillin or other antibiotics

Nitrous oxide

Valium or other sedatives

Latex

Local anesthetic

Codeine or other narcotics

Food

Metal

Others

Please list all prescription medications:

VI. Women Only

Are you or could you be pregnant?

Are you nursing?

Are you taking birth control pills?

If pregnant, what month?

VII. All PATIENTS

Do you have or have you had any other diseases or medical problems NOT listed on this form?

Yes No

If yes, please explain

Have you ever been pre-medicated for dental treatment?

Yes No

If yes, when?

Is there any issue or condition that you would like to discuss with the dentist in private?

Yes No

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.

I authorize the dentist to contact my physician.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Date

Physician's Name

Phone Number

Whom would you like us to contact in case of an emergency?

Name

Relationship

Phone Number

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and /or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient (Parent of Guardian)

Date

Signature of Dentist

Date

MEDICAL UPDATES

I have reviewed my Health History and confirm that it accurately states past and present conditions.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Add Signature

Acknowledgement of Receipt of Notice of Privacy Practices

You May Refuse to Sign This Acknowledgement

have received a copy of the Cupertino Dental Health Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name / Signature

Date

If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following

Personal Representative’s name

Relationship to Patient

For Program Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)

Your information will be encrypted.