ADULT MEDICAL HISTORY. S. 70th Street Lincoln, NE () • () ADULT MEDICAL HISTORY. Name: _____________________________________________ Date: . We ask about your medical and dental history, and your concerns so we can provide the best orthodontic care. COVID Update Lakeshore Orthodontics is dedicated to providing your family with the very best orthodontic care in a supportive and caring manner.
past medical history *Include any chronic/recurring disorder or previously treated problems/diseases which no longer affect you. Examples of chronic/recurring disorders – Recurrent Fungal Infections, Diabetes Mellitus, Chronic Fatigue, etc. Examples of treated problems that no longer affect you – Tuberculosis, Meningitis, etc. Diabetes, Type 2 (adult onset) Eczema Epilepsy (seizures) Genetic diseases Glaucoma Hay fever (Allergic Rhinitis) Hearing Problems Heart Disease High Blood Pressure High cholesterol Kidney diseases Migraine headaches Mitral Valve Prolapse.
Apr 11, · An adult health history form is used to gather health information precisely for a doctor’s clinic, hospital or office of an adult individual. This form is used by doctors when they want to know the medical history of a patient. This is useful as the doctor will know what they are working with. The doctor can remember the past illnesses of the patient concerned with the aid of this form. Adult Medical History. Personal Information Consent Form. Trail Orthodontics is committed to protecting the privacy of our patient’s personal information and to utilizing all personal information in a responsible professional manner. Patient’s Medical and Dental History (and x-rays as required) are GATHERED.
ADULT MEDICAL HISTORY 1. Chiefcomplaint:(☐Hearing(Loss(((☐LeftEar/☐RightEar()(☐Tinnitus/Ringing(☐Dizziness(. No significant history known. Hypertension – high blood pressure. Hyperlipidemia – high cholesterol: Heart Attack, Angina (Coronary Artery Disease) Diabetes Type II (adult onset) Cancer, Breast. Cancer, Colon: Cancer, Prostate. Osteoporosis: Depression. Alcoholism / Drug abuse: Alzheimers. Asthma: Autoimmune Disease. Bleeding or Clotting Disorder.