HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #: Work #: If you are completing this form for another person, what is your name and relationship to that person? * Reason for visit: * Your current physical health is: Good / Fair / Poor Height: Weight: * Are you currently under the care of a physician? Yes / No Date of last visit: If Yes for what: Name of physician: Phone #: Address: * Do you have any allergies? Yes / No List: Are you allergic to (please circle): Penicillin, Sulfa, Clindamycin, Tetracycline, Codeine, Morphine, Ibuprofen, Aspirin, Iodine Tape, Latex, Shellfish, Eggs or Soy Have you ever had any problems with Local Anesthesia? Yes / No Type of Reaction: * Have you ever had any problems with General Anesthesia? Yes / No Type of Reaction: * Do you or a family member have any history of Malignant Hyperthermia (life threatening reaction to general anesthesia)? Yes / No * Are you taking any medications, drugs or pills (birth control / inhalers / aspirin / nitroglycerin / blood thinners / vitamins / Herbs)? Yes / No List: * Have you ever taken cortisone / prednisone or other steroid drugs longer than 2 weeks? Yes / No * Have you ever or are you currently taking bisphosphonate medication for osteoporosis or cancer treatment? Yes / No * Have you ever taken Accutane? Yes / No * Have you had any Operations or been Hospitalized? Yes / No List: * Have you had or do you currently have any of the following? (Circle Yes or No for each one) Y / N Recent Weight Loss Y / N Bronchitis Y / N Heartburn / Reflux Y / N Blood Transfusion Y / N Dieting Y / N Asthma Y / N Ulcer Y / N Cancer Y / N Angioedema (spontaneous swelling) Y / N Difficulty Breathing Y / N Pancreatitis Y / N Tumor Y / N Vitiligo (loss skin pigment) Y / N Snoring Y / N Liver Disease/Hepatitis Y / N HIV + / AIDS / ARC Y / N Acne Y / N Sleep Apnea Y / N Bladder Problem Y / N Sexually Transmitted Disease Y / N Radiation Treatment Y / N Emphysema / COPD Y / N Kidney Disease Y / N Seizures Y / N Chemotherapy Treatment Y / N Tuberculosis Y / N Organ Transplants Y / N Stroke Y / N Dizziness Y / N Chest Pain / Angina Y / N Arthritis Y / N Numbness Y / N Fainting Y / N Heart Attack Y / N Back Pain/Sciatica Y / N Artificial Joints Y / N Frequent Headaches Y / N Heart Murmur Y / N Fibromyalgia Y / N Depression / Anxiety Y / N Hay Fever Y / N Artificial Heart Valves Y / N Osteoporosis/Osteopenia Y / N Other Psychiatric Illnesses Y / N Sinus Problems Y / N Rheumatic Fever Y / N Diabetes Y / N Use Night/Bite Guar d Y / N Heart Failure Y / N Thyroid Problems Y / N Contact Lenses/Glasses Y / N Irregular Heartbeat Y / N Blood Clots Y / N Glaucoma Y / N Pacemaker/ ICD Y / N Abnormal Bleeding Y / N Hearing Problems Y / N Heart Surgery Y / N Bruise Easily Y / N Nasal Congestion Y / N Circulation Problems Y / N Anemia Y / N Nose Bleeds Y / N High Blood Pressure Y / N Sickle Cell Y / N Cold Sores / Fever Blisters Y / N Low Blood Pressure Y / N Porphyria Are there any conditions / problems not listed above you think the doctor should know about? Yes / No List:
Medications Taken: Please circle below the osteoporosis medications that you currently take or have taken in the past. Bisphosphonate Usage: Reclast (IV Zoledronic Acid) Aredia (IV Pamidronate) Boniva (Ibandronate) Fosamax (Alendronate) Benefos (Clodronate) I. Allergies or Reactions to Medications: 1. 2. 3. 4. 5. Zometa (IV Zeledronate), Prolia/Xgeva (Denosumab) Actonel (Risedronate) Skelid (Tiludronate) Didronel Please list the length of time you have used the above medication(s): II. Prescriptive and Non-Prescriptive Medication: 1. 2. 3. 4. 5. Dose(mg/pill) How May Times per Day III. Surgical History: (Please list ALL Surgeries with Dates): 1. 2. 3. 4. 5. IV. Social History: Alcohol: Yes No # drinks per week and for how many years Tobacco: Yes No # packs per day and for how many years Recreational Drugs: Yes No V. Family History: Yes or No Heart Disease/Heart Attacks Genetic Disorders Congenital Heart Problem Cancer Hypertension Malignant Hyperthermia Stroke Diabetes Bleeding/Clotting Disorder Anesthesia Complications: Other: To the best of my knowledge, I have answered every question completely and accurately. I authorize Dr. Patrick Lucaci and staff to furnish information to insurance companies as needed. I authorize payment from insurance company or companies to go directly to this office. I understand that I am financially responsible for charges for my treatment. I consent to the performing of advised and necessary procedures for diagnosis and treatment. Patient (parent/legal guardian) Signature: Date:
Insurance Info: Salina Oral and Maxillofacial Surgery Specialist Patient's Legal Name: First Middle Last Preferred: Physical Address: Postal Address (if applicable): Marital Status: S M W Sep Date of Birth: Age: Gender: Social Security #: School: Full-time: Part-time: Employer: Full-time: Part-time: Occupation: Home ph: ( ) Cell ph: ( ) Work ph:( ) Physicians: Referred by: General Dentist: Medical Doctor: Other: Information About Your: Spouse(Significant Other) Guardian /Parent Name: Date of Birth: Social Security #: Physical Address if different from patient: Employer: Occupation: Home Ph:( ) Cell Ph:( ) Work Ph: ( ) Person Responsible for Account: Self Other (relationship to patient): Name (complete if different from above) Birth Date: SSN: Address: Employer: Occupation: Home Ph:( ) Cell Ph:( ) Work Ph:( )
Emergency Contact: Name: Phone #:( ) Relationship to patient: Dental Insurance: Insurance: Phone #: Policy Holder: DOB: Relation to patient: Social Security #: ID #: Group #: Address to file claims: City: State: Zip: Medical Insurance: Insurance: Phone #: Policy Holder: DOB: Relation to patient: Social Security #: ID#: Group #: Address to file claims: City: State: Zip Code: Secondary Insurance: Dental Yes No Name: Medical Yes No Name: