Patient Medical History - Medications

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NAME: ____________________________________
TODAY’S DATE:____/____/____
AGE: ______
DATE OF BIRTH:___________
SS#:_______________________
Tele (H):_____________________ (W): _______________ (CELL):_______________________
EMAIL: ______________
EMERGENCY CONTACT (NAME, RELATION, TELE):_________________________________
HOW DID YOU HEAR ABOUT US? ________________________________________________
PRIMARY PHYSICIAN (NAME, TELE):_____________________________________________
PHARMACY (NAME, ADDRESS, TELE):____________________________________________
CURRENT MEDICATIONS (prescription, over-the-counter, supplements, herbs):
* ASPIRIN, MOTRIN, ADVIL,COUMADIN, OR VITAMIN E?
YES
NO
* ANTIBIOTICS BEFORE DENTAL PROCEDURES?
YES
NO
ALLERGIES TO MEDICATIONS (antibiotics, pain medications, latex, lidocaine, tapes, antibiotic
ointments):
OCCUPATION: ____________________
DO YOU SMOKE?
YES
NO
IF YES, HOW MANY PACKS PER DAY?___
DO YOU DRINK ALCOHOL?
YES
NO
IF YES, HOW MANY DRINKS PER DAY?___
HIGH BLOOD PRESSURE
YES
NO
*ARTIFICIAL JOINTS
YES
NO
STROKES
YES
NO
ARTHRITIS
YES
NO
HEART ATTACK/FAILURE
YES
NO
*HEPATITIS
YES
NO
IRREGULAR HEART BEAT
YES
NO
*HIV
YES
NO
CARDIAC PACEMAKER
YES
NO
*EASY/PROLONGED
YES
NO
BLEEDING
*HEART VALVE PROBLEM
YES
NO
*BLOOD TRANS-
YES
NO
*ARTIFICIAL HEART VALVE
YES
NO
FUSIONS/PRODUCTS
SEIZURES/EPILEPSY
YES
NO
RECENT SURGERY
YES
NO
TROUBLE BREATHING/LUNG PROBLEMS
YES
NO
INTERNAL CANCER:
YES
NO
TYPE:________________
EYE PROBLEMS (eg. GLAUCOMA)
YES
NO
NERVE PROBLEMS
YES
NO
EARS/NOSE/THROAT PROBLEMS
YES
NO
ORGAN TRANSPLANT
YES
NO
GASTROINTESTINAL PROBLEMS
YES
NO
*DIFFICULT HEALING
YES
NO
GENITAL/URINARY PROBLEMS
YES
NO
*SCARS/KELOIDS
YES
NO
CIRCULATION PROBLEMS
YES
NO
OTHER HEALTH
YES
NO
PROBLEMS (LIST):
DEPRESSION/ANXIETY/PSYCHIATRIC
YES
NO
PROBLEMS
DISEASE (CIRCLE & MARK “X”)
ME
RELATIVE
NO
DON’T KNOW
DIABETES OR THYROID PROBLEMS
LUPUS/AUTOIMMUNE PROBLEMS
MELANOMA/OTHER SKIN CANCERS
ASTHMA/HAYFEVER/ALLERGIES
ECZEMA/ PSORIASIS
QUESTIONS ABOUT COSMETIC DERMATOLOGY
YES
NO
OK TO LEAVE VOICE MAIL FOR LAB & BIOPSY RESULTS @ TELE # _______________
YES
NO
OK TO EMAIL CLINIC ANNOUNCEMENTS & REMINDERS
YES
NO
FOR WOMEN:
ARE YOU PREGNANT, PLAN TO GET PREGNANT, OR BREAST FEEDING
YES
NO

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