口腔门诊病历首页

1、病历号：Patient ID:口腔门诊病历首页New patie ntde ntal history form了解您的个人资料有助于我们为您提供更好的服务，制定更安全的治疗方案，达到最佳的治疗效果， 您的信息绝对严格保密，请您仔细阅读，并用正楷字填写以下内容，谢谢合作！It is important to know details of your medical history as these could affect the success of your dental treatme nt and how we can provide you with effective treatme

2、 nt safely. Please note that all the in formati on on this medical & den tal history will rema in strictly con fide ntial. Please complete in CAPITAL LETTERS.个人信息 Patient Details姓名：Name:性别：Gen der:年龄：Age：出生年月日：年月日民族：职业：D.O.B:YYMMDDMin ority:Occupati on:家庭住址：介绍人：Home Address：Refere nee :联系电话：客户来源：附近居

3、住/工作路过/路牌别人介绍Phon e:Source:网络其他紧急联系人：联系电话：Emerge ncy Con tact:Con tact nu mber:过敏史 Allergy History:药物 Medicine :食物 Food :其他 Others:心脏病 Heart DiseaseO否NO是Y心脏起搏器 Cardiac PacemakerO否NO是丫高血压 HypertensionO否NO是丫糖尿病DiabetesO否NO是丫获得性免疫缺陷 HIV/AIDSO否NO是丫出血性疾病 Excessive Bleedi ngO否NO是丫癫痫史EpilepsyO否NO是丫以上全否NOfo

4、r all:()系统性疾病史Medical History（请在下面打勾Please tick “”）女性患者 For female : 您是否怀孕？ Are you pregnant?您是否长期服用某种药物？如阿司匹林，可的松等。（O否O是）如果有，请列出:甲亢 Thyroid ProblemsO否NO是Y肾脏疾病 Kid ney DiseaseO否NO是丫肝炎 Hepatitis or Liver DiseaseO否NO是丫恶性肿瘤 Malignant TumorO否NO是丫重大手术史Major OperationO否NO是丫骨质疏松症OsteoporosisO否NO是丫其他 Others

5、:(O否N O是Y)Are you tak ing any medicati ons, pills or drugs? (O No O Yes If yes, please expla in:我已认真填写表格，保证所有内容属实。我已充分了解信息错漏对健康的危害，自愿承担因信息错漏 不实而导致的不良后果。To the best of my kno wledge, the questi on on this form have bee n accurately an swered. I un dersta nd that providing in correct information can b

6、e dangerous to my (or patient s) health. It is my responsibility to inform tlden tal office of any cha nges in medical status.客户/监护人签字：与客户关系：Sign atureof Patie nt/ Guardia n: _ Relati on ship:日期：年月日Date: YY MM DD口腔检查表rJIJs625S4、恒牙列o乳牙列o混合牙列o5、有无活动义齿修复体？ （O有，o无）若有，请记录:6、有无种植修复体？ （O有，O无）若有，请记录：1、软垢指数：0 1 2 32、牙石指数：01 2 3龋损或阴影|rn|充填XT桩核It图例说明T *移位，倾斜其他情况请用文字标注说明:冠修复体缺失牙冠伸长3、牙龈指数：0123精品文档交流初诊病历就诊时间：20年月日贴X线片栏贴X线片栏主诉：现病史：既往史：检杳