Hanover Endodontics
William A. Adams, D.D.S Yaakov R. Barak, D.D.S
Practice Limited to Endodontics
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*KEEP CREDIT CARD ON FILE?
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Medical History
(Please select yes or no)
Are you in good health?
*
Yes
No
How long ago was your last physical exam?
*
Any changes in health since last year?
*
Yes
No
Have you had major or minor surgery in the past 5 years?
*
Yes
No
Are you being treated by a physician?
*
Yes
No
If so, for what condition?
Are you now taking any drug or medication?
*
Yes
No
If so, what medication?
Have you ever had an injury to the face, head, mouth, or teeth?
*
Yes
No
Please explain
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Have you ever had any of the following?
(please select yes or no)
High blood pressure
*
Yes
No
Low blood pressure
*
Yes
No
Rheumatic fever
*
Yes
No
Heart murmur
*
Yes
No
Heart condition
*
Yes
No
Artificial valve
*
Yes
No
Blood transfusion
*
Yes
No
Heart pacemaker
*
Yes
No
Artificial joint
*
Yes
No
Kidney disease
*
Yes
No
Hepatitis or jaundice
*
Yes
No
Allergies
*
Yes
No
Sinus trouble
*
Yes
No
Stroke
*
Yes
No
Syphilis/Gonorrhea
*
Yes
No
Thyroid disease
*
Yes
No
Psychiatric treatment or mental disorders
*
Yes
No
Diabetes
*
Yes
No
AIDS/HIV positive
*
Yes
No
Cancer
*
Yes
No
Chemotherapy
*
Yes
No
Lung disease
*
Yes
No
Anemia
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Yes
No
Abnormal bleeding
*
Yes
No
Alcoholism
*
Yes
No
Drug addiction
*
Yes
No
Nervous disorders
*
Yes
No
Epilepsy
*
Yes
No
Sexually transmitted disease
*
Yes
No
Herpes
*
Yes
No
Cold Sores
*
Yes
No
Hay fever
*
Yes
No
Arthritis
*
Yes
No
Asthma
*
Yes
No
Glaucoma
*
Yes
No
Tuberculosis
*
Yes
No
Steroid or hormonal therapy
*
Yes
No
Stomach or intestinal disorders
*
Yes
No
Fibromyalgia
*
Yes
No
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Have you ever had an allergic or unusual reaction to any of the following?
(Please select Yes or No)
Dental local anesthetics
*
Yes
No
Aspirin or Tylenol compounds
*
Yes
No
Codeine or other narcotics
*
Yes
No
Barbituates or tranquilizers
*
Yes
No
Penicillin
*
Yes
No
Erythromycin or other antibiotics
*
Yes
No
Any other drug or medication
*
Yes
No
Latex
*
Yes
No
Is there anything that the dentist should know regarding your medical history that has not been mentioned?
*
Yes
No
Please Explain
Women
If this section does not apply select "This section does not apply to me".
This section applies to me
This section does not apply to me
Are you pregnant?
*
Yes
No
Do you anticipate becoming pregnant?
*
Yes
No
Are you taking birth control pills?
*
Yes
No
If you have an infant, are you breastfeeding?
*
Yes
No
If yes, how many months
To the best of my knowledge all of the proceeding answers are true and correct. If I ever have any change in my health or in my medication I will inform the dentist without fail.
Name
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Date
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