Medical History

Is the patient an Adult or a Child?

Adult Child

First Name

Middle Name

Last Name

Parent or guardian's full name

Name of Current Physician

Phone

Date of Last Visit

How long since your last physical exam?

Please list any prescriptions or other medications or supplements you take.

Are you allergic to any medications or other things? Please describe.

Do you have any problems with penicillin, antibiotics, anesthetics or other medications?

Are you sensitive to any metals or latex?

Yes No

Are pregnant or do you suspect you might be?

Yes No

Do you use birth control medications?

Yes No

Do you have any heart disease or been treated for heart disease?

Yes No

Do you have a pacemaker, artificial heart valve or mitral valve prolapse?

Yes No

Have you ever had rheumatic fever?

Yes No

Are you aware of any heart murmurs?

Yes No

Have you ever had radiation or chemo?

Yes No

Do you have high or low blood pressure?

High Blood Pressure

Low Blood Pressure

Neither

Please describe and surgeries or serious illnesses you have had.

Do you have any inflamatory diseses such s arthritis or rheumatism?

Yes No

Do you have any artificial joints or prosthesis?

Yes No

Do you have any blood diseases such as anemia or leukemia?

Yes No

Have you ever had trouble controlling bleeding?

Yes No

Do you have any stomach problems?

Yes No

Do you have any kidney problems?

Yes No

Do you have any liver problems?

Yes No

Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood or osteoporosis?

Yes No

May I Have Your Permission To Speak Directly With Your Physician(s) Regarding Your Treatment?

Yes No

Have You Ever Been Hospitalized?

Yes No

If Yes, Describe

Are you a diabetic?

Type 1

Type 2

Not diabetic

Do you have fainting or dizzy spells?

Yes No

Do you have asthma?

Yes No

Do you have epilepsy or seizure disorders?

Yes No

Do you or have you ever had venereal or any sexually transmitted disease?

Yes No

Have you tested HIV positive?

Yes No

Do you have AIDS?

Yes No

Have you ever tested positive for T.B.?

Yes No

Have You Ever Experienced An Adverse Reaction During Medical Treatment?

Yes No

If Yes, Describe

Do you smoke, chew or use any form of tobacco?

Yes No

Do you consume more than one alcoholic beverage a day?

Yes No

Do you habitually use controlled substances?

Yes No

Have you ever had psychiatric treatment?

Yes No

Have you ever or do you test positive for Hepatitis?

Yes No

Do you have any disease, condition or problem not listed? If yes, please explain.

Is there anything else we should know about your health that has not been asked in this form?

Would you like to speak to the doctor privately about any problem?

Yes No

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the doctor to help determine appropriate and healthful treatment. If there is any change in my medical status, I will inform the doctor. I authorize the insurance company indicated on this form to pay to the doctor all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the doctor to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Ful Name of Responsible Party

_________________________________________________________
Signature of Responsible Party (to be signed at time of first visit)

_____________________________
Date

Does your child have any health problems?

Yes No

Please describe

Is your child under the care of a physician?

Yes No

For how long and why?

Physician's name and phone number

Does your child take any medications?

Yes No

Please list medications

Is your child allergic to penicillin, antibiotics or other drugs?

Yes No

Please describe

Is your child allergic to or sensitive to any metals or latex?

Yes No

Please describe

Does your child have any other allergies?

Yes No

Has your child had any serious illness?

Yes No

Please describe

Has your child ever had surgery?

Yes No

Please describe

Does your child have a heart murmur?

Yes No

Is surgery contemplated?

Yes No

Does your child experience severe or prolongated bleeding?

Yes No

Does your child have AIDS or has he/she tested HIV positive?

Yes No

Has your child tested positive for hepatitis?

Yes No

Is your child subject to any of the following nervous disorders?

Fainting

Seizures

Dizziness

Behavioral/Learning problems

Does your child have frequent headaches?

Yes No

Does your child have a history of any of the following: diabetes, heart trouble, asthma, kidney infection reheumatic fever, epilepsy, cerebral, palsy, liver problems, congenital birth defects, cognitive disability, eyesight problems, cancer, infections, speech impairments or hearing loss?

Yes No

Please describe

Parent or Guardian Full Name

_________________________________________
Parent of Guardian Signature (to be signed at time of first visit)

____________________
Date

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Medical History

Penfield Family Dentistry