Patient Information

SS# or Patient ID:
LAST NAME
FIRST NAME
MIDDLE INITIAL
Date of Birth
Gender	Male  Female
Height:
Weight:

 

Mailing address:
City:
State:
Zip:
Occupation:
Home Phone:
Business/Cell Phone:
Email:

Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question)
 

Yes No DK	Active Tuberculosis
Yes No DK	Persistent cough greater than a 3 week duration
Yes No DK	Cough that produces blood
Yes No DK	Been exposed to anyone with tuberculosis

If you answer yes to any of the three items above, please stop and return this form to the receptionist.

Medical Information

Please mark your response to indicate if you have or have not had any of the following diseases or problems.

 

Yes No DK	Are you now under the care of a physician? Physician Name: Phone: Address/City/State/Zip:
Yes No DK	Are you in good health?
Yes No DK	Has there been any change in your general health within the past year? If yes, what condition is being treated?
answer to right	Date of last physical exam:
Yes No DK	Have you had a serious illness, operation or been hospitalized in the past 5 years? If yes, what was the illness or problem?
Yes No DK	Are you taking or have you recently taken any prescription or over the counter medicine(s)? If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:

 

Yes No DK	Do you wear contact lenses?
Yes No DK	Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? .. Date:  If yes, have you had any complications?
Yes No DK	Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for osteoporosis or Paget’s disease?
Yes No DK	Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer? Date Treatment began:
Yes No DK	Do you use controlled substances (drugs)?
Yes No DK	Do you use tobacco (smoking, snuff, chew, bidis)? ..  If so, how interested are you in stopping?  VERY  SOMEWHAT  NOT INTERESTED
Yes No DK	Do you drink alcoholic beverages? If yes, how much alcohol did you drink in the last 24 hours? If yes, how much do you typically drink In a week?

Allergies

Are you allergic to or have you had a reaction to:
To all yes responses, specify type of reaction.

Yes No DK	Metals
Yes No DK	Local anesthetics
Yes No DK	Latex (rubber)
Yes No DK	Aspirin
Yes No DK	Iodine
Yes No DK	Penicillin or other antibiotics
Yes No DK	Hay fever/seasonal
Yes No DK	Barbiturates, sedatives, or sleeping pills
Yes No DK	Animals
Yes No DK	Sulfa drugs
Yes No DK	Food
Yes No DK	Codeine or other narcotics
Yes No DK	Other

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Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
 

Yes No DK	Artificial (prosthetic) heart valve
Yes No DK	Previous infective endocarditis
Yes No DK	Damaged valves in transplanted heart

Congenital heart disease (CHD)
Yes No DK	Unrepaired, cyanotic CHD
Yes No DK	Repaired (completely) in last 6 months
Yes No DK	Repaired CHD with residual defects

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. 

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Yes No DK	Cardiovascular disease
Yes No DK	Angina
Yes No DK	Arteriosclerosis
Yes No DK	Congestive heart failure
Yes No DK	Damaged heart valves
Yes No DK	Heart attack
Yes No DK	Heart murmur
Yes No DK	Low blood pressure
Yes No DK	High blood pressure
Yes No DK	Other congenital heart defects
Yes No DK	Mitral valve prolapse
Yes No DK	Pacemaker
Yes No DK	Rheumatic fever
Yes No DK	Rheumatic heart disease
Yes No DK	Abnormal bleeding
Yes No DK	Anemia
Yes No DK	Blood transfusion If yes, date:
Yes No DK	Hemophilia
Yes No DK	AIDS or HIV infection
Yes No DK	Arthritis
Yes No DK	Autoimmune disease
Yes No DK	Rheumatoid arthritis
Yes No DK	Systemic lupus erythematosus
Yes No DK	Asthma
Yes No DK	Bronchitis
Yes No DK	Emphysema
Yes No DK	Sinus trouble
Yes No DK	Tuberculosis
Yes No DK	Cancer/Chemotherapy/Radiation Treatment
Yes No DK	Chest pain upon exertion
Yes No DK	Chronic pain
Yes No DK	Diabetes Type I or II
Yes No DK	Eating disorder
Yes No DK	Malnutrition.
Yes No DK	Gastrointestinal disease
Yes No DK	G.E. Reflux/persistent heartburn
Yes No DK	Ulcers
Yes No DK	Thyroid problems
Yes No DK	Stroke
Yes No DK	Glaucoma.
Yes No DK	Hepatitis, jaundice or liver disease
Yes No DK	Epilepsy
Yes No DK	Fainting spells or seizures
Yes No DK	Neurological disorders If yes, specify:
Yes No DK	Sleep disorder
Yes No DK	Do you snore?
Yes No DK	Mental health disorders  Specify:
Yes No DK	Recurrent Infections  Type of infection:
Yes No DK	Kidney problems
Yes No DK	Night sweats
Yes No DK	Osteoporosis
Yes No DK	Persistent swollen glands in neck
Yes No DK	Severe headaches/migraines
Yes No DK	Severe or rapid weight loss
Yes No DK	Sexually transmitted disease
Yes No DK	Excessive urination
Yes No DK	Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Name of physician or dentist making recommendation: Phone:
Yes No DK	Do you have any disease, condition, or problem not listed above that you think I should know about? Please explain: