Confidential Patient Information
Date
*
-
Month
-
Day
Year
Date
Patient Name
*
First Name
Middle Name
Last Name
Patient Gender
*
Please Select
Male
Female
Age
*
Patient Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
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Area Code
Phone Number
Cell Phone Number
*
-
Area Code
Phone Number
Patient Email
*
example@example.com
Have you ever been a patient of our practice:
Yes
No
Purpose for seeing the Doctor
*
Past Medical History
Patient Height (Ft, Inches)
*
Patient Weight (lbs.)
*
Are you in good health?
*
Yes
No
Have there been any changes in your general health in the past year?
*
Yes
No
Are you currently under the care of a physician?
*
Yes
No
Have you ever been hospitalized or had surgery?
*
Yes
No
Have you, or a family member, had any unusual or serious reactions to general anesthesia?
*
Yes
No
Have you had a heart valve replacement or vascular graft?
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Yes
No
Has a physician recommended that you take antibiotics prior to dental treatment?
*
Yes
No
Do you travel outside the United States?
*
Yes
No
Is there any condition concerning your health that the doctor should be told about?
*
Yes
No
Do you wish to speak to the doctor privately about anything?
*
Yes
No
Have you ever had (Please check all that apply)
*
Acid reflux/Stomach Ulcers
Alcohol/drug addiction
Anemia
Anxiety/Depression
Asthma
Arthritis
Arrhythmia
Bleeding Disorders
Blood Clots
Blood transfusion
Bowel Problems
Broken Bones
Cancer
Cataracts
Chest Pains/Angina
Chronic Smoking Habit
Collagen Vascular Disease
COPD
Diabetes, Non-Insulin Dependent
Diabetes, Insulin Dependent
Diabetes
Digestive Problems
Emotional Disorder
Emphysema
Epilepsy Seizures
Fainting Spells
Gallbladder Disease
Gallstones
Glaucoma
Gout
Headaches
Heart Disease
Heart Attack
Heart Murmur
Heart Valve Problem
Hepatitis
High Blood Pressure
High Cholesterol
HIV/AIDS
Irregular Heart Beat
Hepatitis
Kidney Disease
Kidney Stones
Lung Disease
Liver Disease
Neurological Disorders
Osteoporosis/Osteopenia
Rheumatic Fever
Seasonal allergies
Seizures/Epilepsy
Sickle Cell
Sleep Apnea
Use a C-PAP machine
Stroke
Thyroid Disease
Tuberculosis
Venereal Disease
None listed
Other illnesses:
Please list any Operations and Dates of Each
*
Please list your Current Medications and Dosages:
*
Are you taking any blood thinners?
*
None
Coumadin
Plavix
Elaquis
Xarelto
Aggrenox
Pradaxa
Aspirin
Ginko Biloba
Are you taking, or have you ever taken bone density medications, RANKL inhibitors or bisphosphonates such as Fosamax, Boniva, Actonel, Denosumab, IV Zometa, Aredia, Reclast or Evista in the past 12 years:
*
Yes
No
Have you ever taken diet pills?
*
Yes
No
Are you taking any natural product, herbal supplement or homeopathic remedy?
*
Yes
No
Do you have any known drug allergies?
*
Yes
No
Please list any drug allergies
Do you have any food allergies?
*
Yes
No
Please list any food allergies
Do you have a Latex allergy?
*
Yes
No
Healthy & Unhealthy Habits
Exercise
*
Never
1-2 days
3-4 days
5+ days
Eating following a diet
*
I have a loose diet
I have a strict diet
I don't have a diet plan
Alcohol Consumption
*
I don't drink
1-2 glasses/day
3-4 glasses/day
5+ glasses/day
Caffeine Consumption
*
I don't use caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
Do you smoke?
*
No
0-1 pack/day
1-2 packs/day
2+ packs/day
Have you ever used recreational drugs?
*
Yes
No
If yes, what recreational drugs have you used? How many years? When was the last use?
*
If you are under the care of a physician for pain managment, or recovering from drug addiction please select the medication you are currently taking:
*
Suboxone
Methadone
Oxycodone
Fentanyl
Other
Review of Systems:
Review of Systems:
*
Fatigue
Dizziness
Chest pains or pressure
Chest pains on exertion
Rapid or irregular heart rate
Palpitations
Shortness of breath with exertion
Shortness of breath when laying flat
Pacemaker/Defibrillator
Fever/Chills/Night Sweats
Memory problems
Headaches
Vision changes
Congestion
Ear aches
Hearing problems
Ringing in ears
Sore throat
Difficulty swallowing
Hoarseness/voice changes
Chronic cough
Painful breathing
Nausea/vomiting
Weight gain or loss
Swollen ankles or joint disease
Muscle pain and/or weakness
Convulsions or seizures
Easy bruising
Enlarged lymph nodes
Rash
Delay in healing
Receiving Dialysis
Tumor or growth
Difficutly sleeping
Heat/Cold intolerance
Abnormal thirst
Cancer, radiation or chemotherapy
Problems with immune system
Pain and/or clicking of jaw when eating
Difficulty eating/Change in appetitie
Contagious Disease(s)
None
Family History
Have any of your relatives had any of the following:
High Blood Pressure
*
Yes
No
Heart Disease
*
Yes
No
Diabetes
*
Yes
No
Bleeding Problem/Disorder
*
Yes
No
Cancer
*
Yes
No
Anesthesia Problems
*
Yes
No
This section is for women only:
Women: Is there a possilbilty of pregnancy?
*
Yes
No
Expected delivery date
Are you nursing?
*
Yes
No
Are you taking birth control pills? Note: Antibiotics may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.
*
Yes
No
Conclusion
Include other comments regarding your Medical History
Verification
I certify that I have read and understand the questions answered above. I fully acknowledge that my questions have been answered to my satisfaction. I will not hold my doctor, or any other staff member, responsible for any errors or omissions that I have made in the completion of this form.
*
Signature
Name:
*
Date:
*
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Month
-
Day
Year
Date
I authorize Dr. Anderson and his staff to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers.
*
Signature
Name:
*
Date:
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
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