Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Medical History
Does the patient have any allergies or drug reactions to:
Select here if all answers BELOW are
NO
Latex
Yes
No
Penicillin or Other Antibiotics
Yes
No
Sulfa Drugs
Yes
No
Aspirin, Ibuprofen, Tylenol
Yes
No
Local Anesthetics
Yes
No
Metal Allergy
Yes
No
Other:
Yes
No
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Select here if all answers BELOW are
NO
Heart Murmur
Yes
No
Damaged or Artificial Heart Valves
Yes
No
Congenital Heart Defect
Yes
No
Heart Disease
Yes
No
Rheumatic Fever
Yes
No
Angina
Yes
No
Liver Disease/Jaundice/Hepatitis
Yes
No
Kidney Disease
Yes
No
Heart Attack/Stroke
Yes
No
Hemophilia
Yes
No
Hypertension/High Blood Pressure
Yes
No
Prolonged Bleeding/Transfusion
Yes
No
Anemia/Blood disorder
Yes
No
HIV/AIDS
Yes
No
Tonsils/Adenoids Removed
Yes
No
Handicaps/Disabilities
Yes
No
Arthritis/Joint problems
Yes
No
Large Tonsils
Yes
No
Sinus Trouble
Yes
No
Bed Wetting
Yes
No
Substance Abuse Problem (Past or Present)
Yes
No
Bone Fractures/Trauma to Face/Jaw
Yes
No
Prosthetic Joints
Yes
No
Chronic Fatigue
Yes
No
Diabetes
Yes
No
Growth Problems
Yes
No
Tuberculosis or Lung Disease
Yes
No
Pneumonia
Yes
No
Cancer
Yes
No
Family History of Cancer
Yes
No
Received Radiation Treatment
Yes
No
Arteriosclerosis
Yes
No
Thyroid/Endocrine Problems
Yes
No
Stomach Ulcer or Hyperacidity
Yes
No
Hormone Therapy
Yes
No
Nervous Disorders
Yes
No
Bone Disorders/Bone Loss
Yes
No
Seizures/Epilepsy/Neurological Disease
Yes
No
Treated for Emotional Problems
Yes
No
Asthma
Yes
No
Respiratory Problems/Emphysema
Yes
No
Persistent Swollen Neck Glands
Yes
No
Sexually Transmitted Disease
Yes
No
Low Blood Pressure
Yes
No
Persistent Cough
Yes
No
Heart Condition
Yes
No
Autoimmune Disorder
Yes
No
Are you pregnant?
Yes
No
Do You Take Bisphosphonates (Fosamax, Boniva)
Yes
No
Has there been any change in the patient's general health within the last year?
Yes
No
If any of the above medical questions were answered 'Yes' , please explain: