Language
English (US)
Spanish (Latin America)
Medical & Dental Health History
Patient: Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Primary Care Physician [PCP]
*
Primary Care Physician [PCP] - City
*
Primary Care Physician [PCP] - Phone Number
*
Format: (000) 000-0000.
Are you being treated by a specialist?
*
Yes
No
Specialist Name
*
Specialist - City
*
Specialist - Phone Number
*
Format: (000) 000-0000.
Do you have, or have your recently had, any of the following. [CHECK ALL THAT APPLY]
ADD/ADHD
Convulsions/Seizures
Hives/Rash
Sickle Cell Disease
Alzheimers/Parkinsons Disease
COPD, Emphysema or Asthma
Kidney Problems/Dialysis
Stomach/Intestinal Disease
Anemia
Diabetes/Hypoglycemia
Liver Disease
Stroke
Anxiety or Depression
Fatigue
Mental illness
Swelling of Limbs
Arthritis / Rheumatism
Glaucoma
Nausea
Tyroid Condition
Blood Clot
Headaches
PTSD
Ulcers
Breathing/Lung Problems
Hearing problems/Impairment
Radiation/Chemotherapy
Vision problems/Impairment
Chemical Dependency
High Blood Pressure (Hypertension)
Seizures/Tremors
Weakness
Chest Pain or Discomfort
High Cholesterol
Shingles
Weight loss/gain
Review the following infections diseases and check-off all items that apply to you.
AIDS/HIV
Chicken Pox
Hepatitis
Scarlet Fever
Malaria
Measles
Lyme Disease
STDs
Mumps
Cholera
Encephalitis
Parasite Infection
Poliomyelitis
Rheumatic Fever
Tetanus
Tuberculosis
Whooping Cough
Other
Please list all current medications you are taking. If you are taking more than can be listed, please speak with the patient specialist.
Rows
Medication
Dosage (mg)
Times per Day
1
2
3
4
5
Do you take bisphosphonates (ex: Fosamax, Reclast, Zometa, Atonel, or Boniva)?
*
Yes
No
Dosage (mg) / Times per Day
Do you take blood thinners (ex: Coumadin, Heparin, or Plavix)?
*
Yes
No
Dosage (mg) / Times per Day
Are you allergic to any medications?
*
Yes
No
Please specify:
Do you have allergies to anything other than medication?
*
Yes
No
Please specify:
Have you ever been hospitalized or had a major operation?
*
Yes
No
Please specify:
Are you pregnant or trying to become pregnant?
*
Yes
No
Are you taking oral contraceptives?
*
Yes
No
Are you a current smoker?
*
Yes
No
Are you a former smoker?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Do you use controlled substances?
*
Yes
No
Do you have a "DO NOT RESUSCITATE ORDER"?
*
Yes
No
NOTE: We requires that a copy be on file prior to being seen.
Is this your first visit to a dentist?
*
Yes
No
When was your last visit?
Previous Dentist Name
Signature of Patient/Guardian
*
SUBMISSION DATE
/
Month
/
Day
Year
Date
Submit
Should be Empty: