Medical History

Sex:

Date of Birth:

Date of Last Physical:

Are you in good health?

Have there been any changes to your general health in the past year?

Have you had any serious illness or operation within the last 5 years?

Have you been under the care of a medical doctor during the last two years?

Have you ever had any excessive bleeding requiring special treatment?

Women: Are you pregnant/trying to get pregnant/breast feeding?

Are you undergoing any hormonal therapies?

Do you have any problems with your menstrual period?

Are you allergic to or have you had an allergic reaction or adverse affect to any of the following (please check if yes):

Are you taking oral contraceptives?

Are you taking or have you ever taken any of the following medications (please check if yes):

Chest Pains
Shortness of Breath
Hives/Skin Rashes
Heart Failure
Ulcers
Alcoholism
Heart Disease
Mental Health Issues
Herpes or STD's
Heart Attack
Emphysema
Glaucoma
Heart Problems
Fainting/Dizziness
Steroid Treatment
Depression
Eating Disorder
Arthritis
Congenital Heart Disease
Epilepsy/Seizures
Dental Implant
Liver Disease
Persistent Cough
Dentures/Partials
Hypertension
Tuberculosis
Birth Defects
Heart Murmur
Asthma
HIV+, AIDS, ARC
Rheumatic Fever
Hepatitis A
Hay Fever
Anxiety
Hepatitis B
Tobacco Products
Sickle Cell Disease
Hepatitis C or D
Acid Reflux
Sinus Trouble
Pacemaker
Jaundice
Artificial Joints
Night Sweats
Kidney Trouble
Thyroid Disease
Stroke
Diabetes
Anemia
Drug Addiction
Chemotherapy
Blood Transfusion
Cold Sores
Cancer
Mitral Valve Prolapse
Radiation Therapy
Transplant
Inflammatory Rheumatism
Osteoporosis
Bone Infections
Chest pain after exertion?
Shortness of breath after mild exercise?
Do your ankles swell?
Do you use extra pillows to sleep?
Do you have any blood pressure issues?

Are you now, or have you ever been treated for a psychological disorder?

Have you ever vomited blood?

Do you have diabetes?

Which type do you have? Type 1Type 2

Do you have ANY Diarrhea?

Does anyone in your family have diabetes?

Do you have hypothyroidism or hyperthyroidism?

Is there any family history of blood disorders?

Are you a hemophiliac?

Have you ever had any abnormal bleeding after any surgery, extraction, or trauma?

Have you ever had a blood transfusion?

Do you have an autoimmune disease?

Have you ever undergone chemotherapy or radiation therapy?

Are you regularly exposed to x-rays or ANY other ionizing radiation or substances?

Do you drink alcohol?

Are you wearing contact lenses?

Do you use any other tobacco, nicotine or marijuana or cannabis products?

Do you or have you used any illegal substances?

Are you taking any of the following medications? Please check all that apply.:

Dental History

Date of Last Dental Exam:

Date of Last Dental X-Rays:

Are you having tooth or gum pain at this time?

Do you feel nervous about having dental treatment?

Have you ever had a bad experience in a dental office?

Are you satisfied with the appearance of your teeth?

Do you have headaches, ear aches, or neck pain?

Do you frequently experience sinus problems?

Is there anything you would like to speak with the Doctor about in private?

Are there any other conditions or health concerns you would like to address?

I hereby authorize and request the performance of dental services for myself or for:

I also give my consent for ANY advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or his supervised staff for diagnostic purposes of dental treatment. These records may include study models, photographs, x-rays and blood studies. I understand and acknowledge that I am financially responsible for the services provided for myself and or the above named, regardless of insurance coverage. Treatment plans involving extended credit circumstances are subject to a credit check. I understand that the treatment estimate presented to me is only an estimate. Occasionally, the need may arise to modify a treatment plan. In such case, I will be informed of the need for an additional treatment, and any associated fees.

I understand the importance of a truthful health history and realize that incomplete information may have an adverse effect on my treatment. To the best of my knowledge, the information above is complete and accurate.

Date:

Date:

I acknowledge I have read the following HIPAA terms:
Notice of Privacy Practices

CHRIS WARD DDS
5522 S Lewis Ave
Tulsa, OK 74105
(918) 906-2525

Date:

  • I have been offered and/or received a copy of the currently effective Notice of Privacy Practices for Dr. Chris Ward.
  • I may refuse to sign.
  • Expiration: 3 years from initial/last signature; insurance change; patient reaches age of 18.
  • I understand that I may request a copy of the privacy policies at any time.
  • I understand that my PHI (Protected Health Information) can and will be used for purposes of treatment and for payment from both myself and/or third party.

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR DENTAL INFORMATION:

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY DENTAL APPOINTMENTS, TREATMENT & BILLING INFORMATION AND INFORMATION ABOUT MY DENTAL HEALTH VIA:

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