Microsoft word - medical history.doc

Patient Name________________________ Birth date___________ Today’s Date________________ 1. Are you in good health?________________________________________________________ 2. Are you taking any medications at this time? _____ List_______________________________ ____________________________________________________________________________ 3. Are you currently under a physician’s care? _______ Explain __________________________ 4. Please circle any illness that you have had: glaucoma high blood pressure heart trouble Allergy to latex diabetes bleeding kidney or liver problems HIV/aids tuberculosis Anemia epilepsy asthma artificial joints hepatitis rheumatic fever Fen-Phen 5. Are you taking bisphosphonates (Fosamax, Actonel, Boniva)?___________________________ 6. Is there any other information that should be known about your health or about previous dental visits? _____________________________________________________________________ 7. Have you ever had any other unusual or allergic reaction to an anesthetic or drug (like penicillin)? __________________________________________________________________ 8. In case of an emergency notify:______________________ Telephone#___________________ Endodontic (root canal) therapy is performed to save a tooth which might otherwise need to be removed. The alternatives to endodontic therapy include no treatment, waiting for more definitive development of the symptoms, or tooth extraction. Risk involved in these choices might include pain, infection, swelling and tooth loss. Endodontic or root canal therapy is cleaning, shaping, disinfecting and filling the space inside the root of the tooth. A treated tooth usually functions normally and is a pulpless tooth, not a dead tooth. Treatment will require one or more visits depending upon the condition of the tooth. Almost always a local anesthetic will be needed to anesthetize (numb) your tooth. A minimal number of x-rays will be taken as indicated by the needs of treatment. Please be advised of the following: 1. The root canal fee will vary depending on the tooth being treated and the complexity of the case. Other procedures may incur additional charges. 2. Routine Endodontic cases are successful about 90% of the time. Endodontics, as with any branch of medicine or dentistry, is not an exact science. Thus no guarantee of treatment success can be given or implied. If the original treatment is not successful, it may be retreated, a surgical procedure may be required, or the tooth may need to be removed. Endodontic treatment started in other offices or re-treatment cases may have a different outcome than expected under optimal conditions. 3. Proper post-treatment restoration for the treated tooth is necessary. Please contact your dentist soon after the completion of treatment for the permanent restoration of the tooth. Most teeth will require a crown so do not chew hard foods on the tooth until a permanent restoration has been placed. Otherwise the tooth may break or split, requiring extraction. 4. Possible unavoidable complications of endodontic therapy include but are not limited to: swelling, soreness, discoloration, muscle spasm, fracture of the crown or root of tooth, separation of root canal instruments during treatment, blocked canals due to a filling, prior treatment or natural calcifications, damage to existing crowns/bridges, adverse reactions to anesthetics and medications administered and prescribed for treatment. During treatment complications may be discovered which make treatment impossible or which may require dental surgery. I fully understand the above statement in the consent form. I hereby give my consent to the performance of dental treatment. I further give my consent for the administration of medications, anesthetics and procedures performed understanding the risks involved. _________________________________ ______________ Signature of Patient or Legal Guardian Date

Source: http://www.cascadeendo.net/wp-content/themes/cascadeendo/docs/s/9/MEDICAL%20HISTORY.pdf