口腔門診病歷首頁

1、【下載本文檔，可以自由復(fù)制內(nèi)容或自由編輯修改內(nèi)容，更多精彩文口腔門診病歷首頁New patie ntde ntal history form了解您的個人資料有助于我們?yōu)槟峁└玫姆?wù)， 制定更安全的治療方案， 達(dá)到最佳的治療效果，您的信息絕對嚴(yán)格保密，請您仔細(xì)閱讀，并用正楷字填寫以下內(nèi)容，謝謝合作！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.個人信息 Patient Details姓名：Name:性別：Gen der:年齡：Age：出生年月日：年月日民族：職業(yè)：D.O.B:YYMMDDMin ority:Occupati on:家庭住址：介紹人：Home Address：Refere nee

3、:聯(lián)系電話：客戶來源：附近居住/工作路過/路牌別人介紹Phon e:Source:網(wǎng)絡(luò)其他緊急聯(lián)系人：聯(lián)系電話：Emerge ncy Con tact:Con tact nu mber:過敏史 Allergy History:藥物Medicine:食物Food:其他Others:系統(tǒng)性疾病史 Medical History請在下面打勾 PleasePlease ticktick ）以上全否 NOfor all:()女性患者 ForFor femalefemale： 您是否懷孕？Are you pregnant?（O否NO是Y）您是否長期服用某種藥物？如阿司匹林，可的松等。（O否O是）如果有，請

4、列出:Are you tak ing any medicati ons, pills or drugs?(ONoOYesIf yes, please expla in:我已認(rèn)真填寫表格，保證所有內(nèi)容屬實。我已充分了解信息錯漏對健康的危害，自愿承擔(dān)因信息錯漏 不實而導(dǎo)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，期待你的好評和關(guān)注，我將一如既往為您服務(wù)】病歷號：Patie nt ID:心臟病Heart DiseaseO否NO是丫丫心臟起搏器Cardiac PacemakerO否NO是丫丫高血壓HypertensionO否NO是丫丫糖尿病DiabetesO否NO是丫丫獲得性免疫缺陷HIV/AIDSO否NO是丫丫出血性疾病Excessive Bleedi ngO否NO是Y癲癇史EpilepsyO否NO是丫丫甲亢Thyroid ProblemsO否NO是丫丫腎臟疾病Kid ney DiseaseO否NO是丫

6、丫肝炎Hepatitis or Liver DiseaseO否NO是丫丫惡性腫瘤Malignant TumorO否NO是丫丫重大手術(shù)史Major OperationO否NO是丫丫骨質(zhì)疏松癥OsteoporosisO否NO是丫丫bility toinfoi其他Others:2den tal office of any cha nges in medical status.客戶/監(jiān)護(hù)人簽字：與客戶關(guān)系:Sign atureof Patie nt/ Guardia n: _ Relati on ship:日期：年月日Date:YY MM DD3口腔檢查表87651.3 I 11 2315(i78S7651 32 1J 23 15G7S圖例說明齲損或陰影 充填樁核T *移位，傾斜冠修復(fù)體缺失牙冠伸長其他情況請用文字標(biāo)注說明:44、恒牙列O乳牙列O混合牙列O5、有無活動義齒修復(fù)體？（O有，O無）若有，請記錄:6、有無種植修復(fù)體？（O有，O無）若有，請記錄：初診病歷就診時間：2