HEALTH HISTORY Patient Name: _______________________________________ Date: ___________________________
Are you taking any medications, vitamins and/or herbal supplements? Yes No
* If yes, please provide a list or write medications on the back of this form.
Are you allergic to any antibiotics or any other type of drugs? Yes No If yes, please list ___________________________
_____________________________________________________________________________________________________
Are you allergic to anything else? Yes No * If yes, please explain_______________________________________________
If you have ever taken any of the following medications (or any other medication) for osteoporosis or bone density problems, please list/circle.
If you have had any of the following, please circle.
Do you have any other serious health concerns or conditions? Yes No
*If yes, please explain. _______________________________________________________________________________ Have you ever had to pre-medicate with antibiotics prior to dental treatment? Yes No
*If yes, please tell us the name of the antibiotic. ___________________________________________________________ Have you ever had an adverse reaction to a dental procedure? Yes No How do you feel about the appearance of your teeth? ______________________________________________________ What is your primary dental concern? ___________________________________________________________________ Date of last medical examination: ____________ Name & phone of your doctor: ______________________________
Women Only: -------------------------------------------------------------------------------------------------------------------------------------------
Are you pregnant? Yes No Nursing? Yes No
I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate dental treatment. If there is any change in my medical status, I will inform the dentist. I also understand the use of anesthetic agents embodies a certain risk. Patient (or Guardian) Signature: _____________________________________________ Date: ________________
Current List of Medications Name of Medication Medical Condition Requiring Medication ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________ ________________________________ ______________ ____________________________________
Mary: Mother of God She saw His birth as her son and she saw Him die as her Savior. Angels don't usually make appointments before showing up. She must have felt like she was being congratulated for winning the grand prize in a contest she ha
postage - some banks offer assistance with the completion of this form free of chargeas a customer service). You may also have to register for some if not all of the following: • Provisional Tax • Employees Tax • Income tax • Value Added Tax HOW TO REGISTER A BUSINESS IN NAMIBIA counting officer of close corpora-tion to act as such*• Social security• Trade mark, copyrigh