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

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

YesNo
If Yes Explain
Have you ever been hospitalized or had a major operation?*

YesNo
If Yes Explain
Have you ever had a serious head or neck injury?*

YesNo
If Yes Explain
Are you taking any medications, pills, or drugs?*

YesNo
If Yes Explain
Do you take, or have you taken, Phen-Fen or Redux?*

YesNo
If Yes Explain
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*

YesNo
If Yes Explain
Are you on a special diet?*

YesNo
Do you use tobacco?*

YesNo
Do you use controlled substances?*

YesNo
If Yes Explain
Women: Are you ...

Pregnant/Trying to get PregnantNursing?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 PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseaseHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
Have you ever had any serious illness not listed above?

YesNo
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*

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