Health History Patient NameDate of BirthAddress Street Address City/State/Zip Code ZIP / Postal Code Phone NumberEmail Preferred Pharmacy NamePharmacy NumberMedical HistoryAre you under medical treatment now? Yes No If yes, for what?UntitledHave you been hospitalized for any surgical operation or serious illness within the last 5 years? Yes No If yes, please explainList all medications you are currently taking, including over the counter medications, vitamins, and natural or holistic remedies. Include dose and how often you take itHave you ever needed to take pre-medication (antibiotics) before dental treatment? Yes No Please list all Allergies to MedicinesMedication Add RemoveReaction Add RemovePlease check any medical conditions you had or currently are experiencing (attach sheet if necessary)Medical Conditions Anemia Asthma Chest Pains/Angina Epilepsy Glaucoma Heart Murmur High Blood Pressure/Low BP Liver Disease Pacemaker Rheumatic Fever Stroke Tumors Medical Conditions Arthritis Blood Disease Diabetes Emphysema Heart Injury Hepatitis Jaundice Mental Disorders Radiation Therapy Sinus Problems Thyroid Problem Ulcers Medical Conditions Artificial Joints Cancer Dizziness Fainting Heart Disease HIV/AIDS/STD Kidney Disease Nervous Disorders Respiratory Problems Stomach Problem Tuberculosis Other Are you taking any medication for bone density/biphosphonates? Yes No Are you pregnant/nursing? Yes No Maybe pregnant Are you on Birth Control? Yes No When scheduling your appointment(s), the time is reserved exclusively for you. If you fail to notify us of your inability to keep your appointment, it prevents us from treating another patient in need of emergency care and/or treatment. If you are unable to keep your appointment, please notify us 48 hours in advance to avoid a $50.00 fee. If we are unable to confirm your appointment it may be given to another patient in need of treatment that we are able to confirm.Patient SignatureDate Doctor SignatureDate
