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| Patient's Name (Printed)_________________________________________________________________________Dr's Initials____________ |
Have you ever been treated for any of the following? (Circle yes or no)
Rheumatic Fever
YES
NO
Epilepsy
YES
NO
Rheumatic Heart Disease
YES
NO
Stroke
YES
NO
Heart Trouble (Coronary)
YES
NO
Glaucoma
YES
NO
Angina (chest pain)
YES
NO
Tuberculosis
YES
NO
Hypertension (High Blood Pressure)
YES
NO
Asthma
YES
NO
Do your ankles swell?
YES
NO
Hay Fever
YES
NO
Anemia
YES
NO
Shortness of Breath
YES
NO
Diabetes
YES
NO
Ulcers or Frequent Indigestion
YES
NO
Kidney Disease
YES
NO
Cancer
YES
NO
Liver Disease
YES
NO
Sinus Trouble
YES
NO
HIV/Aids
YES
NO
Jaws pop/click (TMJ)
YES
NO
Have you ever had a serious illness or have you been in a hospital?
YES
NO
If yes, WHAT and WHEN?___________________________________________________________________________________________
________________________________________________________________________________________________________________
Have you been under the care of a physician during the last two years?
YES
NO
If yes, FOR WHAT CONDITION?______________________________________________________________________________________
________________________________________________________________________________________________________________
Have you taken any drugs or medicines in the last year or are you taking any now?
YES
NO
If yes, WHAT?____________________________________________________________________________________________________
________________________________________________________________________________________________________________
Are you allergic to any drugs or medicines?
YES
NO
If yes, WHAT?____________________________________________________________________________________________________
________________________________________________________________________________________________________________
Have you ever had excessive bleeding following a cut, extraction, or surgery?
YES
NO
If yes, HOW LONG?_______________________________________________________________________________________________
_______________________________________________________________________________________________________________
Are you pregnant? YES NO
Are you taking birth control pills?
YES
NO
Are you wearing contact Lenses? YES NO
_________________________________ ______________________
__________________________
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Signature (Patient or Guardian) Date Updated Date
Updated
Date