suzieyangdds.com - MEDICAL HISTORY

Patient Name

First NameLast Name

Patient Account No.

Medical Alert

Physician's Name

Physician Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

1. Have you had any medical care within the past two years?

Descibe

2. Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?

If yes, please list name and dosage:

3. Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs?

4. Are you aware of having an allergic (or adverse) reaction to any substance or medication?

If yes, please specify:

5. Indicate which of the following you have had, or have at present.

Rows	Yes	No
Heart (Surgery, Disease, Attack)
Chest Pain
Congenital Heart Disease
High/Low Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve/Pacemaker
Arthritis/Rheumatism
Swollen Ankles
Stroke
Artificial Joints (hip, knee, etc..)
Kidney Trouble
Ulcers
Diabetes
Thyroid Problems
Glaucoma
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever/Allergy/Hives
Latex Sensitivity
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis A/B/C
A.I.D.S/H.I.V Positive
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Sickle Cell Disease
Bruise Easily
Liver Disease/Yellow Jaundice
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
Psychiatric/Psychological Care

6. Do you have or have you had any disease, condition, or problem not listed?

If yes, please list:

Women

7. Are you pregnant or think you could be pregnant?

Months

Nursing?

8. Do you use birth control prescriptions?

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

Patient/Guardian Signature

Date