ADDRESS IF DIFFERENT THAN ABOVE
In the follow questions, circle yes, aunt check box, whichever applies. Your answers are for our records only and will be considered confidential.
1 .Are you in good health ?
2 .Has there been any change in your general health within the past year?
3 .My last physical examination was on:
4 .Are you now under the care of a physician ?
5 .The name, address & phone number of my physician is:
6 .Have you had any serious illness or operation?
7 .Have you been hospitalized or had a serious illness within the past five (5) years?
8 .Do you have or have you had any of the following diseases or problems ? YES NO
(If yes please check all that apply)
(If yes please check all that apply)
9. Do you have:
(If yes please check all that apply)
10 .Do you bleed easily or have any blood disorders such as anemia?
11 .Have you had surgery, x-ray or drug treatment for a tumor, growth, or other condition of your head or neck?
12 .Do you use tobacco products?
13 .Are you taking any drug or medicine?
14 .How many medications do you take on a regular basis?
15. Are you taking any of the following?
(If yes please check all that apply)
16. Are you allergic or reacted adversely to:
(If yes please check all that apply)
Other (please list)
17. Have you had any serious trouble associated with any previous dental treatment?
18. Do you have any disease, condition, or problem not listed above that we should know about?
(If yes please check all that apply)
19. Are you wearing contact lenses?
20. Have you had anything to eat or drink in the last 4 hours ?
21. Are you wearing removable dental appliances?
22. Are you pregnant?
23. Do you have any problems associated with your menstrual period?
24. Are you nursing?
I hereby authorize Joseph J. Massad, DDS and Associates to obtain verbal and/or written medical information from my physician or family physician to aid in a more complete medical history if needed.
If we need to refer you to another dentist, specialist, or need to contact a family member we will need the following authorization signed for the release of your records.
I authorize Joseph J. Massad, DDS and Associates to release any and all information, which they possess relative to my exam or examination findings, x-rays, and treatment to the referring dentist, specialist, insurance carrier, or family member. I certify that I have read and understand the above. I acknowledge that my questions, if any about the inquiries set forth above have been answered to my satisfaction. 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. Type name and date in the following boxes.
