• RIVERSIDE SMILES, DR. ANN KWOK
    12450-A South Tamiami Trail, North Port, FL 34287
    (941) 423-1777
    Medical History

  • Medical History

  • Are you under the care of a physician?
  • Date of last visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently in good health?
  • Have there been any changes in your general health within the past year?
  • Have you had any illness, operation or been hospitalized in the past 5 years?
  • Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?
  • Are you taking, or have you ever taken, bone density meds, or bisphophonates such as Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Xgeva, Prolia or Reclast in the past 12 years?
  • Do you use tobacco (smoking, snuff, chew)?
  • Do you use controlled substances?
  • Has a physician or previous dentist recommended that you take antibiotics or pre-medication prior to your dental appointment?
  • Do you take any blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil) ?
  • Have you ever had endocarditis?
  • Were you born with a congenital heart defect?
  • Do you have an artificial heart valve?

  • Women Only

  • Are you pregnant or trying to get pregnant?
  • Are you nursing?
  • Are you taking oral contraceptives? yes / no

  • Do you have any allergies?

  • Allergies

  • Do you have any medical conditions? We need this information to keep you healthy and safe

  • Lung or Breathing Conditions
  • Neurological Conditions
  • Heart or Circulatory Conditions
  • Digestive or Dietary Conditions
  • Autoimmune Conditions

  • General Diseases

  • General Diseases Checklist

  • Do you take any medications?

  • Pain Medications

  • Pain Medications Checklist

  • Antibiotics

  • Antibiotics Checklist

  • Antidepressant and Anxiety

  • Antidepressant and Anxiety Checklist

  • Allergy or Asthma

  • Allergy or Asthma Medications

  • Diabetes, Cholesterol, or Blood Pressure

  • Diabetes, Cholesterol, or Blood Pressure Medications

  • General Medications

  • General Medications

  • Pharmacy Information

  • Format: (000) 000-0000.
  • I certify that I have read and I understand the questions asked. I certify I have answered these questions in completion and do not hold the practice, doctor(s), or team responsible for any errors or omission that I have made in completing these forms.

  • Signature

  • Signature By Patient
  • Date signed:
     - -
    2 digit month, 2 digit day, 4 digit year
  • By drawing in the box above I understand and agree that this is a legal representation of my signature

  • Signature By Guardian

  • Date signed:
     - -
    2 digit month, 2 digit day, 4 digit year
  • By drawing in the box above I understand and agree that this is a legal representation of my signature
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  • Should be Empty: