Eaglesoft Medical History

Eaglesoft Medical History

Brandon Hodge, DDS
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking
Patient Name *

First Name Last Name
Birthdate

Month Day Year
Date
Email *
example@example.com
Are you under a physician's care now? *

Yes No
If Yes Explain
Have you ever been hospitalized or had a major operation? *

Yes No
If Yes Explain
Have you ever had a serious head or neck injury? *

Yes No
If Yes Explain
Are you taking any medications, pills, or drugs? *

Yes No
If Yes Explain
Do you take, or have you taken, Phen-Fen or Redux? *

Yes No
If Yes Explain
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? *

Yes No
If Yes Explain
Are you on a special diet? *

Yes No
Do you use tobacco? *

Yes No
Do you use controlled substances? *

Yes No
If Yes Explain
Women: Are you ...

Pregnant/Trying to get Pregnant Nursing? Taking Oral Contraceptives?
Are you allergic to any of the following:

Aspirin? Penicillin? Codeine? Acrylic? Metal? Latex? Sulfa Drugs? Local Anesthetics
Do you have, or have you had, any of the following?

AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice
Have you ever had any serious illness not listed above?

Yes No
If yes explain the illness:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's} health. It is my responsibility to inform the dental office of any changes in medical status.
Signature of Patient, Parent, or Guardian *

Clear
Should be Empty: