Dr. Beckerly - Existing Patient Paperwork (MED HISTORY FORM)

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.

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

When was your last Dental visit? *

Date

Comment

Are you taking any medications, pills, or drugs?*

YesNo

If yes:

Have you ever taken Fosamax, Boniva, Acton el or any other medications containing bisphosphonates?*

YesNo

If yes:

Do you use tobacco?*

YesNo

Penicillin*

YesNo

Aspirin*

YesNo

Latex*

YesNo

Codeine*

YesNo

Sulfa Drugs*

YesNo

Metal or Acrylic*

YesNo

Local Anesthetic*

YesNo

Other

Do you snore?*

YesNo

Have you ever been diagnosed with Sleep Apnea?*

YesNo

AIDS/HIV Positive*

YesNo

Diabetes*

YesNo

Hepatitis B or C*

YesNo

High Blood Pressure*

YesNo

High Cholesterol*

YesNo

Shingles*

YesNo

Asthma*

YesNo

Blood Disease*

YesNo

Stomach/Intestinal Disease*

YesNo

Stroke*

YesNo

Thyroid Disease*

YesNo

Chest Pains*

YesNo

Cold Sores/Fever Blisters*

YesNo

Heart Pacemaker*

YesNo

Cortisone Medicine*

YesNo

Hepatitis A*

YesNo

Renal Dialysis*

YesNo

Rheumatism*

YesNo

Scarlet Fever*

YesNo

Artificial Joint*

YesNo

Fainting Spells/Dizziness*

YesNo

Kidney Problems*

YesNo

Breathing Problems*

YesNo

Cancer*

YesNo

Chemotherapy*

YesNo

Heart Attack/Failure*

YesNo

Pain in Jaw Joints*

YesNo

Parathyroid Disease*

YesNo

Hemophilia*

YesNo

Anaphylaxis*

YesNo

Anemia*

YesNo

Arthritis/Gout*

YesNo

Artificial HeartValve*

YesNo

Excessive Thirst*

YesNo

Irregular Heartbeat*

YesNo

Blood Transfusion*

YesNo

Frequent Headaches*

YesNo

Glaucoma*

YesNo

Mitra I Valve Prolapse*

YesNo

Osteoporosis*

YesNo

Tumors or Growths*

YesNo

Convulsions*

YesNo

Radiation Treatments*

YesNo

Drug Addiction*

YesNo

Emphysema*

YesNo

Epilepsy or Seizures*

YesNo

Excessive Bleeding*

YesNo

Sickle Cell Disease*

YesNo

Sinus Trouble*

YesNo

Leukemia*

YesNo

Liver Disease*

YesNo

Lung Disease*

YesNo

Tonsillitis*

YesNo

Tuberculosis*

YesNo

Congenital Heart Disorder*

YesNo

Heart Trouble/Dis ease*

YesNo

If Yes

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*

Date*

Date

Medical History Form

Are you allergic to any of the following?

Women: Are you...

Sleep Apnea

Do you have, or have you had, any of the following?

Have you ever had any serious illness not listed above?