Confidential Patient Information – II

Patient Name:

Initial Date:

Updated:

Updated:

Updated:

Personal Physician Name:

Personal Physician Address:

YesNo

     1. Have you been hospitalized within the past 2 years? For what?

YesNo

     2. Are you currently being treated by a physician? For what?

YesNo

     3. Are you currently taking any medicines or drugs? What?

YesNo

     4. Have you ever received counseling for excessive use of alcohol and/or prescription drugs?

YesNo

     5. Are you allergic to any drugs? What?

YesNo

     6. Have you ever had a skin rash or other reaction to metal jewellery? To What?

YesNo

     7. Are you allergic to any metals? What?

YesNo

     8. Do you bleed excessively upon injury?

YesNo

     9. Are you pregnant?

YesNo

     10. Have you ever been involved with dental/medical legal activity?

Name:

Address:

Telephone:

(Home)

(Work)