口腔门诊病历首页

1、【下载本文档，可以自由复制内容或自由编辑修改内容，更多精彩文口腔门诊病历首页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 andhow we can provide you with ef

2、fective treatme nt safely. Please note that all the in formati on on this medical & den talhistory 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

3、:联系电话：客户来源：附近居住/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:系统性疾病史 Medical History请在下面打勾 PleasePlease ticktick ）以上全否 NOfor all:()女性患者 ForFor femalefemale： 您是否怀孕？Are you pregnant?（O否NO是Y）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

4、列出:Are you tak ing any medicati ons, pills or drugs?(ONoOYesIf 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 i nformati on can be dan gero

5、us to my (or patie nts) health. It is my resp ons章，期待你的好评和关注，我将一如既往为您服务】病历号：Patie nt ID:心脏病Heart DiseaseO否NO是丫丫心脏起搏器Cardiac PacemakerO否NO是丫丫高血压HypertensionO否NO是丫丫糖尿病DiabetesO否NO是丫丫获得性免疫缺陷HIV/AIDSO否NO是丫丫出血性疾病Excessive Bleedi ngO否NO是Y癫痫史EpilepsyO否NO是丫丫甲亢Thyroid ProblemsO否NO是丫丫肾脏疾病Kid ney DiseaseO否NO是丫

6、丫肝炎Hepatitis or Liver DiseaseO否NO是丫丫恶性肿瘤Malignant TumorO否NO是丫丫重大手术史Major OperationO否NO是丫丫骨质疏松症OsteoporosisO否NO是丫丫bility toinfoi其他Others:2den 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 DD3口腔检查表87651.3 I 11 2315(i78S7651 32 1J 23 15G7S图例说明龋损或阴影 充填桩核T *移位，倾斜冠修复体缺失牙冠伸长其他情况请用文字标注说明:44、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：初诊病历就诊时间：2