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Medical Health History
Please provide current information regarding the Health and Dental History and submit to our practice.
This form is HIPAA-compliant and transmitted surely within our practice. We do not disclose Patient Health Information to any party without your written permission. Please see our website for additional HIPAA compliance and privacy policies.
PLEASE CHECK "YES" OR "NO" as it applies.
Email address
Patient Name:
Your answer
Patient DOB
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Today's Date:
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Patient Gender
Joint swelling or arthritis
Sleep Apnea
Heart problems
Diabetes
Thyroid problems
Kidney problems
Blood pressure problems
Hepatitis or liver problems
Rheumatic fever
Emotional problems
Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity Disorder (ADHD)
Autism Spectrum
Down's Syndrome
Tuberculosis (TB)
HIV positive
AIDS (Acquired Immune Deficiency Syndrome)
Anemia
Asthma, sinus trouble, hay fever
Prolonged bleeding
Endocrine problems
Is the patient pregnant or suspect to be?
Tonsils or adenoids removed?
Any known allergies?
Please list known allergies.
Your answer
Please list medications being taken.
Your answer
Please list physician's name:
Your answer
Please list reason for seeing physician:
Please list any illness(es), condition(s) and or operations not listed above:
Your answer
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