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MEDICAL HISTORY PATIENT NAME Birth Date Although dental personnel primarily treat the area in and around your mouth your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Yes Are you on a special diet Do you use tobacco Do you use controlled substances Women Are you Pregnant/Trying to get pregnant No Have you...
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Have you ever received a stroke? Have you ever received chemotherapy or radiation treatment? Have you had a cancer diagnosis? Have you ever received any other dental work, such as fillings or root canal treatment? Do you have a current dental insurance or is this a health problem that you are not addressing? If so, the insurance that you have or did have, is it current? What was the dental work completed. Why did you select this facility for treatment? Are you a resident of California? How much money will you require for this dental work? How much will it cost? Are you paying cash? How much are you paying out of pocket? Please list the following in order of importance to you: Cost of the procedure — Will you require general anesthesia? Cost of anesthesia — Will there be anesthesiologist, if there will be anesthesiologist? Total cost of the procedure (including anesthesia and all other expenses required) Can you describe the type of the oral surgery you have had already? What experience you've had with dentistry? How long have you been living (or have lived) somewhere else? How long have you been under the care of a family member? How long have you been living independently? How long have you been in public housing? How long did you live in a government assisted (public) program? How long did you live in a housing project that was owned by either the federal government or the city and county of the housing project? Describe recent changes or disruptions you've experienced in your lifestyle. What would you like to change about these changes or disruptions? Describe any recent experiences with any medication, drug or alcohol You might be affected if you have: any severe allergies. Any medical problems with the lining of your blood vessels, lungs, or lungs. A heart defect or any heart disease or condition. Mental or emotional problems that could affect your ability to understand oral surgery. A recent history of a stroke or an arterial malformation. An abnormal blood cell (or tumor) in your blood vessel or any bleeding from any blood vessel in your body. If so, the type of the operation and the location have been listed. The dental facility listed may also be able to perform some tests or treatments that are not included in our fee list. If so, you can speak to the dentist or dental facility to learn more about each type of treatment that is offered.
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Hey how are you doing today my name is Kathy very nice to meet you I'm going to be handling the paperwork with you just pull your pages give our patients the option they would like to print these pages off at home and fill it out and then just simply bring it back to us oh you can come in for an appointment and fill it out then or as we're doing today you can set up an appointment with me and I can help you go through the pages questions medical history mm-hmm, so I'm going to be helping you through this process eight pages to fill out together that the last page doesn't count its one question together we'll be able to finish this rather quickly we're just going to go through this medical history and screening form together okay there are different sections and I just need you to be honest about your medical history your family background mm-hmm will benefit you in the long run as we go through this form if you have any questions for me comments or concerns please let me know, and I can actually include that in your file mm-hmm it's very helpful and useful for your doctors and your nurses any questions during this please don't hesitate to ask that's why we set up this meeting did you have any questions for me before we started this first page here alright, so we're gonna start with just your general information okay can I get your name did you have a middle name that you wanted to add to this can I get your address okay MMM city you have an apartment number or is that just a house or condo no here contact numbers MMM we usually prefer to do you have to like a home number and a cell phone or a home at work or okay so the first one it's a cell phone just go to that that your primary contact number and did you have mm-hmm the second number perfect and can you just verify your birthday for me months hey dear no family physician or primary care provider you are new to our clinic right so do you have your previous doctors do you have out their phone number by chance your phone feel free to look it up oh I'm at number is their address or just travel the clinic name yeah when you look up there at that sign and what city is that in easy Anna all right do we have permission to receive patient file documents regarding your health and hoping from your previous position that'll be helpful for us and if you can just this line right here just as a verification that you give me permission to have those files sent over so just straight there hmm and if you can just initial right so how can I ask your marital status are you single married divorced or widowed and how do you classify your sex now FEMA education did you complete grade school okay and junior high school any form of college and if so how many can I come your occupation position and what's your employer's father or just the general city and what about a work number the best way to contact your manager supervisor just going to go ahead and keep these order for us in your file here next up we're going to...
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