Medical History

Personal Information

Sex:

Male
Female

Date of Birth

Date of Last Physical

Are you in good health?

Yes
No

Have there been any changes to your general health in the past year?

Yes
No

Have you had any serious illness or operation within the last 5 years?

Yes
No

Have you been under the care of a medical doctor during the last two years?

Yes
No

Have you ever had any excessive bleeding requiring special treatment?

Yes
No

Women: Are you pregnant/trying to get pregnant/breast feeding?

Yes
No

Are you undergoing any hormonal therapies?

Yes
No

Do you have any problems with your menstrual period?

Yes
No

Are you taking or have you ever taken any of the following medications (please check if yes):

Fosamax
Actonel
Boniva Aredia
Reclast
Zometa
Prolia
Xgeva
None

Please list other CURRENT medications you are taking:

Do you have or have you ever had any of the following?

Chest pain after exertion?

Yes No

Shortness of breath after mild exercise?

Yes No

Do your ankles swell?

Yes No

Do you use extra pillows to sleep?

Yes No

Do you have any blood pressure issues?

Yes No

(If yes, explain below)

Are you now, or have you ever been treated for a psychological disorder?

Yes No

Have you ever vomited blood?

Yes No

Do you have ANY Diarrhea?

Yes No

Do you have diabetes?

Yes No

Does anyone in your family have diabetes?

Yes No

Do you have hypothyroidism or hyperthyroidism?

Yes No

Is there any family history of blood disorders?

Yes No

Are you a hemophiliac?

Yes No

Have you ever had any abnormal bleeding after any surgery, extraction, or trauma?

Yes No

Have you ever had a blood transfusion?

Yes No

Do you have an autoimmune disease?

Yes No

If yes, what condition is being treated, and how?

Have you ever undergone chemotherapy or radiation therapy?

Yes No

Are you regularly exposed to x-rays or ANY other ionizing radiation or substances?

Yes No

Are you wearing contact lenses?

Yes No

Do you drink alcohol?

Yes No

If so, how much and how often?

Do you smoke?

Yes No

If so, how much do you smoke?

Are you a former smoker?

Yes No

If so, when did you quit?

Do you use any other tobacco, nicotine or marijuana or cannabis products?

Yes No

If so, what product and how much and how often?

Do you or have you used any illegal substances?

Yes No

If so, what have you used, when was your last use, how much and how often?

Are you taking any of the following medications? Please check all that apply.

Anticoagulants/Blood Thinners
Tranquilizers
Ibuprofen/Tylenol Codeine or other Narcotics
Aspirin
Steroids
Iodine
None
Other

Dental History

Are you having tooth or gum pain at this time?

Yes
No

Do you feel nervous about having dental treatment?

Yes
No

Have you ever had a bad experience in a dental office?

Yes
No

Are you satisfied with the appearance of your teeth?

Yes
No

Do you have headaches, ear aches, or neck pain?

Yes
No

Do you frequently experience sinus problems?

Yes
No

Is there anything you would like to speak with the Doctor about in private?

Yes
No

Are there any other conditions or health concerns you would like to address?

Yes No

What is your chief complaint, what brings you in today? Example - "I'm missing too many teeth because they were pulled when young and they started breaking because I can only chew with my front teeth. "

I hereby authorize and request the performance of dental services for myself or for:

I authorize

I also give my consent for ANY advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or his supervised staff for diagnostic purposes of dental treatment. These records may include study models, photographs, x-rays and blood studies. I understand and acknowledge that I am financially responsible for the services provided for myself and or the above named, regardless of insurance coverage. Treatment plans involving extended credit circumstances are subject to a credit check. I understand that the treatment estimate presented to me is only an estimate. Occasionally, the need may arise to modify a treatment plan. In such case, I will be informed of the need for an additional treatment, and any associated fees.

I understand the importance of a truthful health history and realize that incomplete information may have an adverse effect on my treatment. To the best of my knowledge, the information above is complete and accurate.

Date

CHRIS WARD DDS
5522 S Lewis Ave
Tulsa, OK 74105
(918) 906-2525

Patient Name:

Date

I have been offered and/or received a copy of the currently effective Notice of Privacy Practices for Dr. Chris Ward.
I may refuse to sign.
Expiration: 3 years from initial/last signature; insurance change; patient reaches age of 18.
I understand that I may request a copy of the privacy policies at any time.
I understand that my PHI (Protected Health Information) can and will be used for purposes of treatment and for payment from both myself and/or third party.