• Date of birth*
     / /
  • Format: (000) 000-0000.
  • Are you being treated for any medical conditions at the present time or have been treated within the last year?*
  • Have there been any changes in your general health in the last year?*
  • Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*
  • Do you have any allergies? If you answered yes, please list using the categories below:*
  • Have you ever had an uncommon or adverse reaction to any medicines or injections?*
  • Do you have or have you ever had asthma?*
  • Do you have or have you ever had any heart or blood pressure problems?*
  • Do you have or have ever had a replacement or repair of a heart valve, an infection of the heart(i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*
  • Have you ever had hepatitis, jaundice or liver disease?*
  • Do you have a prosthetic or an artificial joint?*
  • Do you have a bleeding problem or a bleeding disorder?*
  • Have you ever been hospitalized for any illness or operations?*
  • Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?*
  • Do you have or have you ever had any of the following? Please Check
  • Are there any conditions or disease not listed above that you have or have had?*
  • Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)*
  • Do you smoke or chew tobacco products?*
  • Are you nervous during dental treatment?*
  • For Women: Are you pregnant?

  • The Information I have given above is true to the best of my knowledge

  • Date*
     / /

  • PHIA permits us to collect and use your personal health information. In certain circumstances, PHIA also allows us to share it with others both inside and outside our organization. We do this for purposes such as:

    To provide you with health care;

    To get payment for your care which could include private insurers;

    To do health system planning and research;

    To report as required by law;

  • Unless you tell us not to, we can share your personal health information with any health care provider who has, is or will be providing you with health care. Members of your health care team are only allowed access to the information they need to give you the care you need. If you tell us not to share your information with a health care provider, we will not share your information unless permitted or required by law to do so. Please tell a member of your health care team if you do not want your information shared with a health care provider.

  • Date
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