New Patient Health HistoryThree Pages Below

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Health History Update Two Pages Below

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East Hampton Dental Group

Check any current medical conditions:

( ) Mental Disorders ( ) Artificial Joints ( ) Jaundice

( ) Sinus Problems ( ) Lupus ( ) Osteoporosis Meds

( ) Nervous Disorders ( ) Rheumatic fever ( ) Tumors

( ) Stroke ( ) Blood Disease ( ) Kidney Disease

( ) Rheumatism ( ) Dizziness/Fainting ( ) Asthma

( ) Excessive bleeding ( ) Epilepsy ( ) Diabetes

( ) Stomach Problems ( ) Cancer ( ) Congenital Heart Disease

( ) Anemia ( ) Radiation Treatment ( ) Lyme Disease

( ) HIV ( ) Heart Murmur ( ) Liver Disease

( ) Arthritis ( ) Heart Valves ( ) Hepatitis A B C

( ) Herpes ( ) Head Injuries ( ) Heart Disease

( ) Pace Maker ( ) Low Blood Pressure ( ) High Blood Pressure

( ) Respiratory Problems ( ) Ulcers ( ) Glaucoma

( ) Tuberculosis ( ) Pregnant/ Nursing

Due Date: ___________

Please list other conditions below

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Patient First Name: Middle: Last:

Mailing Address:

City: State: Zip Code:

Home Phone: Mobile: Other:

Email:

Are you required to pre-medicate?

i.e. Hip/shoulder replacement etc.

If yes, please check drug:

( ) Amoxicillin: __________________mg

( ) Clindamycin: _________________mg

( ) Erythromycin: ________________mg

( ) Other: _______________________mg

Known Allergies

( ) Hay Fever/Seasonal

( ) Local Anesthetic: Type? __________________

( ) Penicillin

( ) Codeine

( ) Sulfa Drugs

( ) Latex

( ) Erythromycin

( ) Other: _____________________________

Please list any medication you are currently taking

Please list any other changes in your health or surgical history

PLEASE NOTIFY THE FRONT DESK IF YOUR DENTAL INSURANCE INFORMATION HAS CHANGED.

I have reviewed the information and answered all questions to the best of my knowledge. I understand this information will be used to determine the dental treatment I receive at this office. I will notify the office should any information change in the future. ________________________________________ _____________________________________ Patient/Parent Guardian Signature Date

COVID-19 Questionnaire One Page Below

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COVID‐19 ‐ PATIENT DISCLOSURE

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the

circumstance of the COVID‐19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer

treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for

contracting COVID‐19. Please disclose to us any condition that compromises your immune system and understand that

we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you

have experienced any signs or symptoms associated with the COVID‐19 virus.

YES NO

Do you have a fever or above normal temperature? ☐ ☐

Have you experienced shortness of breath or had trouble breathing? ☐ ☐

Do you have a dry cough? ☐ ☐

Do you have a runny nose? ☐ ☐

Have you recently lost or had a reduction in your sense of smell? When? _____________ ☐ ☐

Do you have a sore throat? ☐ ☐

Have you been in contact with someone who has tested positive for COVID‐19?

When? _____________

☐ ☐

Have you tested positive for COVID‐19? When? _____________ ☐ ☐

Have you been tested for COVID‐19 and are awaiting results? When? _____________ ☐ ☐

Have you traveled outside the United States by air or cruise ship in the past 14 days? ☐ ☐

Have you traveled within the United States by air, bus or train within the past 14 days? ☐ ☐

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system

and have disclosed to my provider any conditions in my health history which may result in a compromised immune

system. By signing this document, I acknowledge that the answers I have provided above are true and accurate.

____________________________________ ____________________________________

Patient/Guardian Name (PRINT) Patient/Guardian Signature

____________________________________

Date