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CONFIDENTIAL MEDICAL INFORMATION
Patient’s Name:___________________________________ DOB: ________________ Home Phone: ( ) __________________
Street Address:__________________________________________________________ Work Phone: ( ) __________________ City:____________________________________ State:____________ ZIP:____________ E-Mail ___________________________ Social Security Number:_____________________ Sex: M Male M Female Emergency Contact: _______________________________Phone: ____________________ Relationship ____________________
Spouse’s Name:_________________________________Employer: ____________________________________________________
Primary Physician: ________________________________Phone:_____________________ City & State _____________________
Date of Last Physical Examination: ______________________Date of Last Blood Test/Workup: ____________________________ Other Physicians or Specialists:
Name:______________________ Specialty:_____________ Phone:_________________City & State: ________________________ Name:______________________ Specialty:_____________ Phone:_________________City & State: ________________________ If you are completing this form for another person:
Your Name:_______________________Relationship:_______________ Phone: ( ) ___________________________________ Within the last three years have you been hospitalized or had surgery? Yes No
If yes, please give reasons and dates: ____________________________________________________________________________
Have you ever been instructed to take ANY medications or take ANY special precautions before any dental appointments?
M Yes M No If yes, please explain: ____________________________________________________________________________
1. Are you taking any medications for osteoporosis? M Yes M No
2. Are you taking any drugs, medications, or treatments at this time? M Yes M No
(If you brought a complete written list with you; please give that to the receptionist.)
Prescribed: _______________________________________________________________________________________________
_________________________________________________________________________________________________________ Over-The-Counter Meds (such as aspirin, ibuprofen, allergy meds, sleeping aids, Vitamins, Natural or Herbal Preparations,
and Dietary Supplements):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________ Are you having, or have you ever had radiation or chemotherapy treatments? M Yes M No
If yes, for how long? ________ Name of facility performing the therapy: ____________________________________________ 3. Are you allergic to, or have you ever experienced any unusual reaction to:
4. Are you allergic to or have you ever had any reaction to the following drugs?
M Aspirin/Ibuprofen (Advil, Motrin, Nuprin) 5. Have you had an allergic reaction or unusual response to ANY other medications, drugs, pills or treatments? M Yes M No
If yes, please list: ____________________________________________________________________________________________ Continue on Back…
Do you have, or have you ever had any of the following? (Please check yes or no for each question.)
6. a. Congenital Heart Defects
7. a. Asthma
b. Hay Fever, Skin or Food Allergies or Allergies in General d. Tuberculosis, Emphysema or Lung Disorder M h. Rhumatic Heart Disease/Rhumatic Fever M j. Heart Valve(s) Damage/Mitral Valve Prolapse M l. Ulcers, Acid Reflux, or Stomach Problems M m. A Compromised Immune System (Lupus, HIV, AIDS, Radiation Immune Problems,ect.) M n. An Active Sexual y Transmit ed Disease (STD) M p. Been Treated for Any Psychiatric Condition M r. Excessive Bleeding from any Cut or Incident M 8. Women Only:
t. Any Artificial Joint, Joint Surgery, or Prosthesis M If yes, what joint or area? ________________________ Date of surgery: ________________________________ u. Hepatitis, Jaundice, or Other Liver Problems M If Hepatitis, type? _______________________________ Are you taking hormone replacement therapy? M 9. Do you have any other conditions, diseases, medical problems, or is there ANY other information that you would like us
to know about or that we should be made aware of?
M Yes M No If yes, please explain:
________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ For Office Use Only
___________________________________________________ Patient Signature:
Provider:

Source: http://www.drperna.com/media/941/health-history.pdf

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