3. Are you now, or have you been in the past year, under the care of a physician?
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- Osborne Elliott
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1 Medical History Patient Name Birth Date ID Number 1. Do you have any of the following diseases or problems? Today s Date a. Active Tuberculosis b. Persistent cough greater than 3 weeks in duration c. Cough that produces blood d. Been exposed to anyone with Tuberculosis e. Describe positive and/or unanswered questions 2. What is your impression of your health? a. Date of last physical exam 3. Are you now, or have you been in the past year, under the care of a physician? 4. Have you had any serious illness, operation, or been hospitalized in the past 5 years? 5. Have you had an organ transplant? 6. Do you have a history of Endocarditis (infected heart valve)? 7. Have you had open heart surgery? a. If yes, when was your heart surgery (year)? b. Was an artificial heart valve implanted? 8. Have you had an orthopedic total joint (e.g. hip, knee, elbow, finger) replacement? 9. Have you ever had any radiation therapy or chemotherapy for a growth, tumor or other condition? 10. In the last 2 years, have you taken or are you now taking steroids (e.g. cortisone)? 11. Do you use or have you used tobacco (smoking, snuff, chew, bidis)? a. If yes, please specify amount per day: b. For how many years c. If yes, how interested are you in stopping University of the Pacific, Arthur A. Dugoni School of Dentistry 12. Do you drink alcoholic beverages? a. If yes, how many drinks did you drink in the last 24 hours? b. If yes, how many drinks do you typically drink in a week? c. If yes, are you alcohol dependent? d. If yes, how long have you been alcohol dependent (months)? e. If yes, have you received treatment? 1 P age
2 13. Do you use prescription or street drugs or other substances for recreational purposes? a. If yes, how often do you use? b. If yes, are you drug dependent? c. If yes, how long have you been drug dependent (months)? d. If yes, have you received treatment? 14. Have you taken, are you taking or are you scheduled to begin taking? a. Oral bisphosphonates (Alendronate (Fosamex, Fosamex Plus D), Etidronate (Didronel), Ibandronate (Boniva), Risedronate (Actonel), Tiludronate (Skelid))? b. If yes, what drug, dose and frequency? c. If yes, what for? d. If yes, when? 15. Have you taken, are you taking or are you scheduled to begin taking? a. Intravenous bisphosphonates (Clodronate (Bonefos), Pamidronate (Aredia) or Zolodronic Acid (Reclast, Zometal))? b. If yes, what drug, dose and frequency? c. If yes, what for? d. If yes, when? 16. Women only: a. Are you pregnant? b. Are you trying to become pregnant? c. Are you nursing? d. Are you taking birth control pills, fertility drugs or hormonal replacement? ALLERGIES: Are you allergic to or have you had a reaction to any of the following? For yes responses, please specify type of reaction: 17. Local anesthetics (or their preservatives) 24. Hay fever/seasonal (allergic rhinitis) 18. Penicillin 25. Animals 19. Sulfa drugs 26. Metals/Jewelry (nickel/chrome) 20. Other antibiotics 27. Food 21. Codeine or other narcotics 28. Iodine 22. Aspirin 29. Latex (rubber) 23. Barbiturates (sedatives or sleeping pills) 30. Other/Other Medication(s) 2 P age
3 MEDICAL CONDITIONS: Do you have or have you had any of the following diseases, problems, or symptoms? If yes, please specify: 31. Cardiovascular/Heart problem a. Rheumatic fever/ rheumatic heart disease b. Infective endocarditis c. Artificial heart valves d. Congenital heart defect e. Heart murmur f. Mitral valve prolapsed g. Angina (chest pain) h. Heart attack i. Heart failure j. Coronary heart disease 32. Respiratory/Lung problem a. Asthma b. Emphysema/COPD c. Tuberculosis d. Sarcoidosis e. Pneumonia 33. Diabetes/Endocrine disorder a. Diabetes b. Thyroid problems c. Adrenal gland disorder 34. Kidney/Urogenital disorder a. Kidney stones b. Renal failure/insufficiency c. Dialysis 35. Cancer or Tumors a. Malignant b. Benign k. High blood pressure l. Low blood pressure m. Arteriosclerosis n. Palpitations o. Arrhythmia (irregular heart beat) p. Shortness of breath q. Swelling of the ankles r. Pacemaker s. Implantable defibrillator t. Sleep on two or more pillows f. Sinusitis g. Bronchitis h. Persistent cough i. Sleep apnea j. Snoring d. Prostate e. Frequent urination 3 P age
4 36. Neurologic/Nerve problem a. Stroke b. TIA (transient ischemic attack) c. Seizures/epilepsy d. Multiple sclerosis e. Parkinson s disease f. Neuropathies g. Dementia/Alzheimer s (memory loss) h. Headache i. Fainting or dizzy spells 37. Blood/Hematologic disorder a. Anemia b. Thalassemia c. Sickle cell disease/trait d. Deep vein thrombosis e. Bruise easily 38. Gastrointestinal (GI) disorder a. Cirrhosis/chronic hepatitis b. Jaundice (skin/eyes turn yellow) c. Hepatitis d. Heart burn e. Acid reflux (GERD) 39. Musculoskeletal/Connective tissue disorder a. Arthritis b. Osteoporosis c. Gout d. Temporomandibular joint disorder 40. Infectious disease a. HIV b. AIDS c. Methicillin-resistant Staph aureus (MRSA) j. Weakness k. Feeling of tingling or numbness l. Mental health disorder m. Post traumatic stress disorder n. Obsessive/compulsive disorder o. ADD/ADHD (attention deficit disorder) p. Feelings of anxiety q. Feelings of depression f. Leukemia g. Lymphoma h. Multiple myeloma i. Bleeding disorders f. Gall stones g. Ulcers h. Crohn s disease i. Irritable bowel syndrome e. Lupus f. Sclerodema g. Fibromyalgia h. Joint replacement d. STD (sexually transmitted disease) e. Cold sores f. Mononucleosis 4 P age
5 41. Head/Eye/Ear/Nose/Throat problem a. Vision problems b. Wear contact lenses c. Glaucoma 42. Dermatologic/Skin problem a. Psoriasis(dry skin) b. Other 43. Eating disorder a. Bulimia b. Anorexia 44. Immunosuppression d. Cataract e. Hearing impairment 45. Family history of diabetes: If yes, who? 46. Family history of heart disease: If yes, who? 47. Family history of cancer/tumors: If yes, who? 48. Do you have any other problem, disease or condition not listed above? 5 P age
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MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
MEDICAL HISTORY FORM FOR FOLLOW-UP
MEDICAL HISTORY FORM FOR FOLLOW-UP ID NUMBER: 0a) Form Date... / / 0b) Staff Code... Instructions: Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost
Twohig Dentistry Dental and Oral Health Information
Twohig Dentistry Dental and Oral Health Information Patient s name: Date: Please describe any specific dental problem or discomfort you are having at this time: How long has it been present? If you have
Three Rivers Ayurveda-Patient Medical History
Three Rivers Ayurveda-Patient Medical History Name: DOB: Date: As a new patient, we first would like you to answer the questions below so that we can get an idea of your past medical history. On page 5
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact