www.drchildreth.com - Patient Information/Health History Form

  • PATIENT INFORMATION

  • Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have a secondary dental insurance?*

  • MEDICAL INFORMATION

  • Have you ever had any serious trouble associated with any previous dental treatment?*
  • Does dental treatment make you nervous?*
  • Date of last dental visit
     - -
  • Last dental x-rays
     - -
  • Last cleaning
     - -
  • Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?*
  • Are you happy with your smile?*
  • Do you premedicate with an antibiotic prior to dental treatment?*
  • Do you take Biophosphates, bone density medication/ supplement?*

  • MEDICAL HISTORY 

  • Are you in good health now?*
  • Are you now under the care of a physician?*
  • Have you been hospitalized, had a serious illness, or had surgery in the last 2 years?*
  • Have you ever had excessive bleeding following an extraction, or do cuts take longer to heal now than previously?*
  • Do you smoke, vape, or use oral tobacco?*
  • Do you use marijuana of any type?*
  • Do you use alcoholic beverages? (More than two drinks per day)*
  • Do you or have you used a Night Guard?*
  • Do you use a CPAP?*
  • (Women) Are you pregnant?*
  •  If yes, give due date *
     - -

  • Have you ever had any of the following illnesses or conditions? 

  • Rheumatic Fever*
  • Heart Murmur*
  • High Blood Pressure*
  • Abnormal EKG*
  • Irregular Heartbeat*
  • Pains in Chest*
  • Stroke*
  • Thyroid Disease*
  • Hepatitis*
  • HIV Positive*
  • Heart Attack*
  • Artificial Heart Valve*
  • Jaundice*
  • Liver Disease*
  • Asthma*
  • Hay Fever*
  • Bronchitis*
  • TB*
  • Diabetes*
  • Sexually Transmitted Disease*
  • TMJ Symptoms*
  • Snoring*
  • Sleep Apnea*
  • Pacemaker*
  • Epilepsy/Seizures*
  • Cancer or Tumor*
  • Glaucoma*
  • Kidney Disease*
  • Lung Disease*
  • X-Ray Therapy*
  • Psychiatric Treatment*
  • Ulcer*
  • Artificial Joints*
  • Date*
     - -

  • Are you allergic or have you ever experienced any reaction to the following?

  • Local Anesthetic*
  • Sulfa Drugs*
  • Penicillin*
  • Other Antibiotics*
  • Aspirin*
  • Codeine*
  • Ibuprofen*
  • Latex*
  • Barbituates/Sedatives/Sleeping Pills*
  • Other*

  • Are you taking any of the following? 

  • Antibiotics / Sulfa Drugs*
  • Blood Thinners*
  • Blood Pressure Medication*
  • Thyroid Medicine*
  • Cortisone / Steroids*
  • Recreational Drugs*
  • Antihistamines/ Allergy Drugs / Cold Remedies*
  • Tranquilizers*
  • Insulin / Other Diabetes Drugs*
  • Digitalis/ others*
  • Heart Medication*
  • Nitroglycerin Prescribed*
  • Aspirin*
  • Birth Control Pills*
  • Biophosphates*
  • Other*

  • List the name of the current medication and dosages below:

  • Is there any disease, condition or problem not listed above, or are there any activities your doctor tells you not to do?*

  • MEDICAL HISTORY REVIEW

  • CONSENT & FINANCIAL AGREEMENT

  • ADULT & CHILD CONSENT: I hereby consent to and authorize Dr. Childreth and his assistants or associates to perform dental treatment they deem necessary and reasonable. I consent to the administration of such anesthetics, antibiotics, analgesics and all sedative agents as the doctor may deem advisable and proper. I understand there are risks involved and that complications can occur.

  • FINANCIAL: I understand that responsibility for payment for dental services provided in this office for myself and my dependents is mine. I hereby authorize payment to the above dentist of any insurance benefits otherwise payable to me. A finance charge of 18% per month will be applied to unpaid balances over 120 days old. Rebilling charges of $5.00 are assessed on a balance over 120 days when no payment is received during the billing month.

  • Date*
     - -

  • Jeff Childreth DMD
    3546 Lone Pine Road, Medford, OR. 97504
    541-772-8846, fax 541-732-1878
    frontoffice@drchildreth.com

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