PATIENT PERSONAL HEALTH INFORMATION
DATE
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Month
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Day
Year
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Full Name
Prefix
First Name
Middle Name
Last Name
Suffix
What Brings You to Our Office?
*
Toothache
Wisdom Teeth
Dental Implants
Biopsy
Single bad tooth
Impacted cuspid/eyetooth
Replace Missing Teeth
Sores/growths:tongue, cheeks, lips,
Multiple bad teeth
Other impacted teeth
Poorly fitting dentures
Burning mouth or tongue
Other tooth issues
Bone Grafting for Implants
Other conditions?
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Yes
No
If "Other", please list:
Please type in other conditions:
Taking prescription or over-the-counter Meds for this Condition?
*
Please Select
Yes
No
If Yes, check below:
Antibiotics
Please Select
Amoxicillin
Augmentin
Cleocin/Clindamycin
Keflex
Cephalexin
Erythromycin
Z-pak
Other
If Other, list below:
Prescription Pain Meds
Please Select
Hydrocodone 5.0
Hydrocodone 7.5
Hydrocodone 10
Hydrocodone Liquid
Vicodin 5
Vicodin 7.5
Vicodin 10
Percocet 5
Percocet 7.5
Percocet 10
Oxycodone 5.0
Oxycodone 7.5
Oxycodone 10.5
Ultram/tramadol
Demerol
Other
If Other, list below:
Over-the Counter
Please Select
Tylenol/Acetaminophen
Aspirin
Ibuprofen/Advil/Motrin
Aleve/naproxin
Other
If Other, please list below.
Other Meds You Are Taking for this Condition:
Type in other meds you are taking:
Choose One:
1. Completely healthy and fit. No physical
limitations
2. Mild well-controlled medical issues with no or
minimal functional limitations and/or smoke
products but no COPD, and/or I am pregnant.
3. Functional limitations due to several different
medical conditions, which are controlled by
medical treatment, and/or smoking COPD that
affects breathing
4. Debilitating or incapacitating medical conditions
which significantly limit my lifestyle
What is your General Health Status? Please choose one of the following options:
Choose Yes or No
Yes
No
Physician's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
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Area Code
Phone Number
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Normal Healthy, no physical or mental issues
Mild controlled systemic disease, controlled
Currently Under Physician's Care
*
Please Select
Yes
No
Choose:
Previous Surgery or Anesthesia?
*
Please Select
Yes
No
Choose:
Complications or Difficulties?
*
Please Select
Yes
No
Choose:
Describe complications or difficulties:
Allergies?
*
Please Select
Yes
No
Check all allergies:
*
Local Anesthetics (Xylocaine, lidocaine, Novacaine, Marcaine, articaine, Septocaine,)
Epinephrine
Penicillin, Amoxicillin, Ampicillin, Augmentin Antibiotics
Cleocin, clindamycin
Erythromycin, Z-Pak or azithromycin
Sulfa
Aspirin, Advil, Motrin, ibuprofen, naproxen, Aleve
Other NSAIDS
Codeine
Vicodin, Lorcet, Lortab, hydocodone
Percocet, oxycodone
Valium, Versed, barbiturates
Sleeping pills
Iodine
Latex or rubber products
Eggs or fish
Metals, jewelry, topical chemicals
Anaphylactic Shock
Malignant Hyperthermia
Other Allergies or Sensitivities
*
Please Select
Yes
No
Please list:
Current Prescription Medications
*
Please Select
Yes
No
Antibiotics?
*
None
Amoxicillin, Penicillin
Augmentin
Cleocin, clindamycin
Keflex, Cephalexin
Erythomycin
Z-pak, Azythromycin
Other, list below
Narcotic Pain Prescriptions?
*
None
Vicodin
Hydocodone
Lorcet
Lortab
Percocet
Oxycodone
Fentanyl patch
Sublimaze Patch
Morphine
Other, list below
NSAIDs
*
None
Aspirin
Anaprox/Naproxin
Motrin/ibuprofen
Celebrex/celecoxib
Indomethicin
Toradol/ketorolac
Voltaren/diclofenac
Other, list below
Check all medications:
*
Antibiotics
Amoxicillin, Penicillin, Augmentin
Cleocin, clindamycin
Keflex, cephalexin
Other antibiotics, list below
Narcotic pain medications
VIcodin, Lortab, Lorcet, hydrocodone
Percocet, oxycodone
Other Narcotic meds, list below
Prescription NSAIDS
Aspirin for pain, headaches or blood thinning?
Osteoporosis Drugs
Blood Pressure medications?
Blood Thinners
Coumadin, warfarin
Plavix, clopidogrel
Xarelto, rivaroxaban
Pradaxa, dabigatran
Other, please list below
Cholesterol Drugs
Heart Drugs such as digitalis, Inderal, others
Steroid, Cortisone, Prednisone, etc.
Stomach Acid Blockers
Sedatives, tranquilizers, sleeping pills
Meds for Depression or Bipolar disorder
ADD, ADHA, Hyperactivity Meds
Insulin or Oral Anti-Diabetic drugs
Oral or Intravenous Chemotherapy for Cancer
Medications or injections for allergies?
Other Other Prescription Medications?
*
Please Select
Yes
No
List other medications:
Heart Conditions?
*
Please Select
Yes
No
Check Heart Conditions:
*
Rheumatic Fever or Rheumatic Heart disease
Heart Murmur
Damaged Heart Valves?
Heart valve replacement, artificial heart valves
Congenital Heart Disease
High Blood Pressure
Low BloodPressure
Coronary Artery Disease
Angina
Rheumatic Fever or Rheumatic Heart disease
Heart Murmur
Damaged Heart Valves
Heart valve replacement, artificial heart valves
Congenital Heart Disease
High Blood Pressure?
Low BloodPressure
Coronary Artery Disease
Other Heart Conditions?
*
Please Select
Yes
No
List:
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