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Protecting You and Your Environment Part I Patient Information Patient Name: _ Date of Birth: Sex: Race: Address: _ City: _ Zip: _ Telephone/Home: _ Work/Emergency: _ l.D. Number: _ Social Security Number: _ Parents/Guardian/Spouse: _ Head of Household: _ Date of Birth: _ Does the Patient have Medicaid? Yes: No: (Policy Number) Other insurance/Medicaid HMO? (ComponyJ (Policy Number) Has the Patient completed the eligibility process for health department services? Yes: No: Has the Patient ever been to this dental clinic? Yes: No: Does the Patient receive a "free lunch"? Yes: No: When did the Patient last visit a dentist? (Date) (Dentist/Location) What dental work was done (i.e. exam,fillings,extrications, other)? _ Who is the Patient's physician? _ (.4ddress) (Physician :S Name) Last Office (Date) Part II Medical History Last Physical Examination: (DateJ Please Circle Yes or No Is the Patient in good health? Yes No If not, explain: _ Is the Patient taking any medicine, drugs, herbs or non-prescription supplements? Yes No Please list all: _ Does the Patient use: Alcohol Yes No Tobacco Yes No Recreational Drugs Yes No Is the Patient allergic to penicillin? Yes No Does the patient have any other allergies: Yes No Medicines (list) _ Latex or Rubber Yes No Dental Anesthetic (numbing) Yes No Any other allergies _ PATIENT DENTAL RECORD 4/02 Is the Patient pregnant?. . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Is the Patient breast-feeding?. . . . . . . . . . . . . . . . . . . . . . Yes No Has the Patient had: Cancer Yes No Leukemia Yes No Tumor. Yes No (Date) (Physician/Onco/ogisr) (S11rgel)·/Chemotherapy/Radiation) Does the Patient have: Asthma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Other Respiratory Problems. . . . . . . . . . . . . . . . . . . . . . . Yes No ( continued) Loudoun County Health Department ---PAGE BREAK--- ) (continued) Does the Patient use an inhaler or medications Dialysis/Transplant Yes No For breathing? Yes No Epilepsy/Seizures Yes No Does the Patient have HIV or AlDS? Yes No Arthritis/Joint Pain Yes No Pain in Jaws/TMJ Yes No Has the Patient ever had any of the following conditions: Artificial Joint Yes No Heart Disease Yes No Growth/Development Conditions Yes No Heart Valve Replacement Yes No Birth Defects/Premature Birth Yes No Stroke Yes No Developmentally Delayed Yes No Heart Murmur Yes No Hyperactivity/ ADD/ ADHD Yes No High Blood Pressure Yes No Autism Yes No Rheumatic Fever Yes No Cerebral Palsy Yes No Diabetes Yes No Hearing/Speech Conditions Yes No Sickle Cell Anemia Yes No Conditions Yes No Bleeding Disorders Yes No Sexually Transmitted Disease Yes No Anemia Yes No Drug Addiction Yes No Hepatitis Yes No Is there a history of any of these problems Tuberculosis Yes No In the past? Yes No G · /Th "d/GI d I c d" · y N Is there anything else we should know? 01ter yro1 an u ar on 1t1ons . . . . . . . . . . . . . . . es o Kidney Problems Yes No Medical History Update Part III Consent The infonnation given in Parts 1,1! and II of this fonn is accurate to the best ofmy knowledge of belief. Informal Consent Problems arising from dental treatment are extremely rare but may include pain or infection. Not treating dental disease may have the same result. !f a tooth cavity is very deep and the nerve and blood supply are affected, or if bone loss or swelling are present, the removal of the nerve of the tooth with local anesthesia, may be necessary. Please feel free to discuss any concerns you have with the Public Health Dentist. I authorize the Public Heath Dentist to perform on my child or myself a dental examination and treaanent such as cleaning, treatment of gum disease. fluoride and sealant applications, fillings with local anesthesia and other treatments as deemed necessary by the dentist. Date: Signature: (Patient/Parent/Guardian) Notice of Deemed Consent for HIV, HBV and HCV Testing If one of our health care professionals, workers or employees should be directly exposed to your blood or body fluids m a way that may transmit disease. your blood will be tested for infection with Human Immune deficiency Virus (HIV, the AIDS Virus) and for the presence of the Hepatitis Band Hepatitis C Viruses. A physician or other health care provider will tell you and that person the result of the test and provide counseling, if necessary. If you should be directly exposed to blood or body fluids of one of our heath care professionals, workers or employees in a way that may transmit disease, that person's blood will be tested for infection with Human Immune deficiency Virus (HIV, the AIDS Virus) and for the presence of the Hepatitis Band Hepatitis C Viruses. A physician or other health care provider will tell you and that person the result of the test and provide counseling, if necessary. Date: Signature: (Patient/Parent/Guard,an) PATIENT DENTAL RECORD 4/02 Loudoun County Health Department