Janis moriarty, dmd * pascale berty, dmd

Janis Moriarty, DMD
Medical History Update
As a policy we require our patients to update their medical history in its entirety annually as it is
required by the MA Board of Registration in Dentistry. All information is kept confidential.

Patient Name: _________________________________________________ Birthdate: ____/____/____

Address: ______________________________________ City, State & Zip: __________________________
(H) Phone #: __________________ Cell #: __________________ Business Phone: ________________
E-mail Address: ________________________________________________________________________
Sex: ___ M ___ F Age: _______ Status: ___Single ___Married ___Widowed ___Separated ___ Divorced
Has your Dental Insurance changed since your last visit with us? ___ NO ___ YES
If YES, please see the front desk receptionist.
Notify in case of an emergency: _______________________________________________________________
Physician’s Name & Phone #: ________________________________________________________________
Any serious illnesses or operations? ____ Y ____ N If YES, describe_______________________________________
Are you required to take an antibiotic before certain dental procedures? (Ex: Joint replacement)
____ Y ____N If YES, describe & did you take it for today’s visit: ___________________________________________
If there has been a change that conflicts with our practices and you no longer require premedication we require a note
from your physician or surgeon to keep on file before you can be treated.
Do you take Coumadin or any type of blood thinner presently? ____ Y ____ N
If YES, date blood levels last checked: ___________ INR Level:___________ If you do not have this information please
see the front desk.
WOMEN: Are you pregnant: __Y __N Nursing: __Y __N Taking birth control pills? __Y __N
CHECK Y for Yes and N for NO for the following:
__Y __N AIDS/HIV
__Y __N Circulatory problems __Y __N Hemophilia __Y __N Arthristis,Rheumatism __Y __N Dry Mouth __Y __N Artificial heart values __Y__N Epilepsy __Y __N Atopic (allergy prone) __Y __N Gastrointestinal Disease __Y __N Mitral Valve Prolapse __Y __N Thyroid disease __Y __N Back problems __Y __N Psychiatric care __Y __N Tuberculosis __Y __N Headaches/Migraines __Y __N Rapid weight loss/gain __Y __N Venereal disease __Y __N Chemical dependency __Y __N Heart murmur __Y __N High Blood Pressure __Y __N Respiratory disease If you have your medications and allergies listed on a separate piece of paper we will be happy to make a copy to save you time. List medications you are currently taking, if any: List drug or material allergies, if any: ___________________________________________ ___________________________________________
PATIENT SIGNATURE: _________________________________________________ DATE: _________________
YEAR: _________

Source: http://www.myhealthysmile.net/docs/Medical%20Hx%20Update%20Form.pdf