Consent For Use And Disclosure Of Health Information - The Rector Dental Group

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THE RECTOR DENTAL GROUP
3905 N Wheeling Ave.
Muncie, IN 47304
The information given will be used in strict confidence to prepare your dental chart.
Date:__________________
Birth date:________________
Name:__________________________________________________________________Age:_______
Family Physician:___________________________________________Date of last visit:___________
Whom may we thank for referring you to us:_______________________________________________
Purpose of today's visit (any specific concerns):____________________________________________
___________________________________________________________________________________
Do you have or have you had a history of any of the following?
Heart problems, murmur or surgery.............Yes No
Kidney problems.................................Yes No
Rheumatic fever...........................................Yes No
Hepatitis or jaundice............................Yes No
High or low blood pressure.........................Yes No
Fainting spells......................................Yes No
Congenital heart lesions..............................Yes No
Stroke...................................................Yes No
Blood disorders (anemia, etc).....................Yes No
Stomach problems or ulcers.................Yes No
Bleeding problem or hemophilia................Yes No
Thyroid condition.................................Yes No
Seizures or epilepsy....................................Yes No
Nervousness....................................... Yes No
Asthma, tuberculosis or lung problems......Yes No
Tumors, growths or cancer...................Yes No
Arthritis.......................................................Yes No
Psychiatric treatment...........................Yes No
Venereal Disease.........................................Yes No
Other (please explain)..........................Yes No
__________________________________________________________________________________
__________________________________________________________________________________
Circle One
Are you in good health................................................................................................................Yes
No
Has there been any change in your general health within the past year......................................Yes
No
Are you under the care of a physician.........................................................................................Yes
No
If so, what is the condition being treated____________________________________________
Have you had any serious illness or operation............................................................................Yes
No
If so, what was the illness or operation_____________________________________________
__________________________________________________________________________________
Have you had abnormal bleeding associated with a previous extraction or surgery....................Yes
No
Are you taking any drugs or medications.....................................................................................Yes
No
If so, what____________________________________________________________________
Are you allergic or have you reacted adversely to any drug or medication.................................Yes
No
If so, what____________________________________________________________________
Have you had serious trouble associated with any previous dental treatment.............................Yes
No
Do you have any disease, condition or problem not listed above that I should know about......Yes
No
If so, explain_________________________________________________________________
__________________________________________________________________________________
Women
Are you pregnant..........................................................................................................................Yes
No

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