S15 - Patients Medical History-merged

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Chart #/ID*
If you are a dental patient, enter the first three letters of your last name. If unknown, enter "NA"
Today's Date*

MonthDayYear
Date
A thorough medical history is an important part of your record. Please answer all questions accurately becasue it will allow is to provide you the best possible treatment from a fully informed health professional.

If you don't know, or do not understand the question, either answer to the best of your ability and review the form with a screener, or wait to fill out this form with a screener so you are able to ask questions.
1. Are you in good health?*

YesNo
2. Has there been any change in your general health within the past year?*

YesNo
3. My last medical examination was on:*
Enter a date in the mm/dd/yyyy format. Try to be as specific as possible.
4. Are you know under the care of a physician?*

YesNo
If yes, the name and address of the physician is:
5. Have you every been hospitalized for any serious illness or operation?*

YesNo
If yes, please explain
6. Do you currently have a cough, chest or head cold, or sore throat?*

YesNo
7. Do you currently have any lip sores?*

YesNo
8. Do you have any Allergies?*

YesNo
If yes, check all that apply

Asthma or hay feverHives or skin rash
9. Do you have diabetes?*

YesNo
If yes, check all that apply

I have to urinate (pass water) more than 6 times a day.I'm thirsty most of the time.My mouth frequently becomes dry.I have a blood relative that has diabetes.
10. Do you have arthritis?*

YesNo
If yes, check all that apply

Inflammatory rheumatism (painful swollen joints)Joint replacement
11. Do you currently have or previously had any of the following diseases or problems? Check all that apply.*

Rheumatic fever; rheumatic heart diseaseHeart murmurCongenital heart defectsHigh blood pressureHeart disease, heart attack, coronary insufficiency, coronary occlusion, arteriosclerosis, strokeDo you have pain in your chest upon exertion?After mild exercise, do you have shortness of breath?Do your ankles swell?Do you get shortness of breath when you lie down or do you require extra pillows when you sleep?Fainting spells or seizures (epilepsy)Stomach ulcersKidney troubleHave you recently had any unexpected weight loss?Have you recently had night sweats or a slight fever?Do you have persistent cough and cough up blood?None apply to me at this time
12. Have you had, or currently have, a sexually transmitted disease?*

YesNo
If yes, check all that apply

GonorrheaSyphilisHerpes
13. Do you have a bleeding disorder?*

YesNo
If yes, check all that apply

Are you hemophiliac?Have you had abnormal bleeding associated with previous surgery or trauma?Do you bruise easily?Do you have any blood disorder such as anemia (thin blood)?Have you ever required a blood transfusion? If so, please explain the circumstances in the "Other" field belowOther
14. Have you ever had surgery, chemotherapy, or X-ray treatment for a tumor, growth, or other condition?*

YesNo
If yes, please explain
15. Have you recently taken, or are you currently taking, any of the following medications? Check all that apply.

Antibiotics or sulfa drugsAnticoagulantsMedicine for high blood pressureTranquilizersAspirinTylenolMotrinInsulin, tolbutamide (Orinase) or similar drug for diabetesDigitalis or drugs for heart troubleNitroglycerinAntihistamineOral contraceptiveHormone therapyNone apply to me at this timeOther
16. Have you ever taken prescription medication for weight reduction (diet pills)?*

YesNo
If yes, check all that apply

Fen-Phen (fenfluramine + phentermine)Pondimin (flenfluramine)Redux (dexfenfluramine)
If you have ever taken any of the above drugs, have you had a medical exam to ensure that your heart valves were not affected?

YesNo
17. Are you taking or have you taken cortisone or steroids within the last 2 years?*

YesNo
18. Are you allergic, or have you reacted adversely to (check all that apply):*

Local anestheticsPenicillin or other antibioticsBarbiturates, sedatives, or sleeping pillsAspirinIodineCodeine or other narcoticsMetalsLatexNone apply to me at this timeOther
19. Do you smoke (cigarettes, cigar, vape, etc.)?*

YesNo
20. Do you use smokeless tobacco?*

YesNo
21. How much alcohol do you consume in a day?*
Please indicate if you drink none or as little as a couple times a week.
22. Have you ever been in a drug or substance rehabilitation program?*

YesNo
23. Do you wearing contact lenses?*

YesNo
24. Are you pregnant?*

YesNo
25. Do you have any disease, condition, or problem not listed above? If so please explain*
If none, enter "NA"
This form is asking for a list of every medication you take, what your assigned dosage is, what condition you have that requires you to take it, and how often you take it.

Leave this section blank if you do not currently take any medications.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Chart #/ID
If dental patient, enter the first three letters of your last name. If unknown, leave blank.
Today's Date

MonthDayYear
Date

Please list all medications you are currently taking. If you take more than 15 medications, please let your screener know so they can add the information to your forms.

	Medication Name	Dosage	Reason	How Often Taken
Med 1
Med 2
Med 3
Med 4
Med 5
Med 6
Med 7
Med 8
Med 9
Med 10
Med 11
Med 12
Med 13
Med 14
Med 15

Patient Electronic Signature
Responsible Party Electronic Signature
Date Completed

MonthDayYear
Date
Should be Empty: