Patient Information
Date
*
-
Month
-
Day
Year
Date
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Residence
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Health History
Are you currently under the care of a physician?
*
Yes
No
Physician's Name
*
Physician's Phone Number
*
Please enter a valid phone number.
If yes, what are you being treated for?
*
Most Recent Blood Pressure & Date of Reading
Have you ever had a serious illness, hospitalization, surgery, or other general health problems?
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Yes
No
If yes, please explain.
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Are you currently taking any tablets, pills, or medicines?
*
Yes
No
If yes, please list those medications:
*
Have you ever taken any bone loss prevention drug?
*
Yes
No
If yes, please list if it is Fomax, Actonel, Boniva, or other.
*
PLEASE CHECK ALL THAT APPLY. Have you ever had or been treated for:
*
Abnormal bruising or healing
Acid Reflux
AIDS
Allergies
Alzheimer/Dementia
Anemia Past
Anemia Present
Anxiety
Arthritis
Asthma
Autism
Bleed Easily
Blood Disorder
Blood Thinners
Blood Tranfusion
Cancer
Chemotherapy
Radiation Treatment
Chronic Mouth Dryness
Cold Sores/Herpes Incident
Depression
Diabetes (Blood Sugar)
Digestive Problems/Celiac
Dizziness
Emphysema/COPD
Epilepsy or Seizures
Glaucoma
Hay Fever
Headaches
Heart Attack
Heart Disease
Heart Mitral Valve Prolapse
Heart Murmur
Heart Pacemaker
Heart Valve Replace
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Hives
HIV
HPV
Low Blood Pressure
Injury to Face/Mouth/Teeth
Kidney Problems
Liver Problems
Organ Transplant
Joint Replacement/ Prosthetic
Osteoporosis
Rheumatic Fever
Scarlet Fever
Sinus Problems
STD Positive Test
Stroke
Thyroid
Tuberculosis
Ulcers or Intestinal Problems
Women: Are you pregnant?
None of the above
Please list type and approximate date.
*
Any disease, condition, or problem not listed?
Are you sensitive or allergic to:
*
Aspirin
Codeine
Erythromycin
Iodine
Latex
Local Anesthesia
Metals
Norco
Penicillin
Plastic
Sedatives
Sleeping Pills
Sulfa
NONE
**Other**
If other, please specify.
*
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