Patient Form Pg2

Health Information

REFERRAL INFORMATION

How did you first hear of our practice?
If other, please list:
Have you ever had any of the following? Please check those that apply:

Conditions with Additional Information Required

Congenital Heart Disease
Have you had this condition
Residual Defects
Date
Heart Surgery
Have you had Heart Surgery
Date
Artificial Joints
Do you have Artificial Joints
Date
Type
Pregnancy
Are you pregnant
Due Date
Please list any allergies or other conditions
Name of Physician
Phone
Please list any disease, condition or problem not listed above?
Do you smoke or use smokeless tobacco
Have you ever had any complications following dental treatment?
Have you ever had excessive bleeding requiring special treatment?
Have you been admitted to hospital or needed emergency care during the past two years?
Have you ever taken Bisphosphonate Medications? Please click those that apply
Are there any other Bisphosphonate Medications you have taken?
Are you now under the care of a physician?
Are you taking any drugs or medications (Prescription, Over the Counter)? (List Below)
Medication Name
Dose
Reason
Warfarin
Antidepressants
Codeine (Disprin)
Cortisone
Ginko Biloba
St Johns Wort
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