Confidential Medical History Form Annual Update
Please answer the following questions as fully as possible. Your answers will remain confidential and will only by used by Dr Ling-Feng Soo for the purposes of your dental care.
Patient Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of your family dentist
When was your most recent dental check up?
Are you in the middle of any other dental care?
Crowns
Fillings
Dentures
Bridges
Root canal therapy
Other
Name of regular hygienist if you are not seeing us for ongoing supportive periodontal care (hygienist name & clinic email).
When was your most recent hygiene visit?
Doctors Caring for You
Local physician / Family doctor
Specialist (e.g. Cardiologist for chest pain)
Allergies & Medications
Have you had any allergies or side effects from medications, food, plasters or insects? Please list them.
List all your present medications and any that you have taken in the past 6 months. Please indicate what each is for. e.g. insulin for diabetes.
What illnesses or operations have you had in the previous 12 months?
Checklist: Over the previous 12 months
Did you have any chest pain that could have been from the heart?
Do you have an abnormal heart valve or heart murmur?
Have you had a blackout or ‘funny turn’?
Are you troubled with pain or aching in the stomach or abdomen?
Have you had jaundice or hepatitis?
Have you experienced any abdominal bleeding or bruising?
Do you have diabetes?
Is there any chance you could be pregnant?
Did you smoke in the previous 6 months?
How much alcohol do you drink in one week?
Are there any other health issues you wish to discuss?
Preferred Method of Contact -Appointment Reminders
SMS Text
Email
Phone
Preferred Method of Contact-Clinical Recalls
SMS Text
Email
Phone
Signature
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