Full name/title from to Signature Full name/title from to Signature Full name/title from to Signature Full name/title from to Signature Full name/title from to Signature Full name/title from to Signature Practice management Sample/Diagnostic test tracking log Patient name Test Risk Management: A practical guide for dentists Date ordered Date received 53 54 Sample/Patient information update Patient name Todays date 1 . Has your name changed since your last visit here? Yes No If yes, what was your previous name? What name do you use for health insurance if different than above? 2 . If you have a new or different address since your initial visit, please indicate below . 3 . Has your marital status changed? Yes No 4 . Has your phone number changed? Yes No If yes, new phone number 5 . Has your employment changed? Yes No If yes, new employer name, address and phone 6 . Please note any changes in your health since your last visit . Illness

Accident Allergies Medications, including OTCs or herbal remedies Other Date Signature Practice management Sample/Medical history update Patient name Todays date Date of birth Sex Wt . Ht . Age Occupation Ethnicity Are you presently in good health? Yes No If no, please explain Past serious illnesses? Yes No If yes, please explain Are you being treated for any illnesses? Yes No If yes, please explain List all medications you take including OTCs and herbal remedies . Allergies to medications? Yes No If yes, please list Date of last physical exam Is there a chance you are pregnant? Yes No Have you ever had a blood transfusion? Yes No List all surgeries in the past . Any reaction to anesthesia? Yes No Do you use tobacco products? Yes No If yes, how much and for how long? Do you drink alcoholic beverages? Yes No If yes, how much and for how long? Have you seen other doctors for the problem that brings you here today? Yes No

If yes, please describe Risk Management: A practical guide for dentists 55 56 Do you have a past history of (check all that apply): Headaches Glaucoma High blood pressure Bleeding disorders Heart problems Lung problems Hearing problems Ulcers Snoring Mouth-breathing Reproductive disorders Psychiatric problems Street drug use Emotional problems Frequent infections Bad scarring Thyroid problems Circulatory problems Family history of (check all that apply): Cancer Diabetes Heart disease Anesthetic problems Asthma Comments Practice management Sample/Facsimile notice Date To Fax Phone Pages From

Comments The information contained in this facsimile transmission is privileged and confidential . It is intended for the use of the individual or entity named above . If you are not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited . If you have received this fax in error, please notify us immediately by telephone and destroy the document . Risk Management: A practical guide for dentists 57 58