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# Medical History Wisdom Teeth Official Clinical Data Record Submission
Name | [Full Legal Name]
Street Address | [Street Address]
City | [City]
Postal Code | [Postal Code]
Date of Birth | [mm/dd/yyyy]
Home | [000-000-0000]
Cell | [000-000-0000]
Health Card Number | [0000-XX]
General Health Assessment
1. Are you having pain or discomfort at this time? Response: [YES/NO]
2. Do you feel very nervous about having dental treatment? Response: [YES/NO]
3. Have you ever had a bad experience in the dental office? Response: [YES/NO]
4. Have you been a patient in the hospital during the past two years? Response: [YES/NO]
5. Have you been under the care of a medical doctor in the past two years? Response: [YES/NO]
6. Have you taken any medicine or drugs during the past two years? Response: [YES/NO]
7. Are you allergic to (itching, rash, swelling of hands, feet or eyes) or made sick by penicillin, aspirin, codeine, or any other drug or medication? Response: [YES/NO]
Medications | [Patient's Response / List of medications]
8. Have you ever had any excessive bleeding requiring special treatment? Response: [YES/NO]
Reported Health Conditions Present:
• Rheumatic Fever • Anemia • Sinus Trouble • [Other Selected Conditions]
Physical Wellness Indicators
9. When you walk up stairs or take a walk do you ever have to stop because of pain in our chest, shortness of breath or because you are very tired? Response: [YES/NO]
10. Do your ankles swell during the day? Response: [YES/NO]
11. Do you use more than 2 pillows to sleep? Response: [YES/NO]
12. Have you lost or gained more than 10 pounds in the past year? Response: [YES/NO]
13. Do you ever wake up from sleep short of breath? Response: [YES/NO]
14. Are you on a special diet? Response: [YES/NO]
15. Has you medical doctor ever said you have cancer or a tumor? Response: [YES/NO]
16. Do you have any disease, condition or problem not listed? Response: [YES/NO]
Details | [Patient's Explanation]
Women Only Are you pregnant? Response: [YES/NO] Do you anticipate becoming pregnant? Response: [YES/NO]
TO THE BEST OF MY KNOWLEDGE, ALL OF THE PRECEDING ANSWERS ARE TRUE AND CORRECT. IF I EVER HAVE ANY CHANGE IN MY HEALTH, OR IF MY MEDICATION CHANGES, I WILL INFORM THE DOCTOR AT THE NEXT APPOINTMENT WITHOUT FAIL.
Digital Signature Record [Digitally Endorsed by Patient] | Date Signed [mm/dd/yyyy]
Financial Agreement Summary
Insurance Carrier: [Carrier Name] Policy Holder: [Name and DOB] Policy / Cert #: [Contract Info] * A Charge of $75.00 for less than 48 hours' notice of cancellation appointment applies.
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