Provider Information Your Name (required) Your Email (required) Family Physician: Date of last visit: Specialty: Date of last complete physical: Address: City: State: Zip Code: Phone # with Area Code: Additional Physician: Date of last visit: Specialty: Address: City: State: Zip Code: Phone # with Area Code: Additional Physician or Health Provider, such as Chiropractor, Naturopath, Homeopath, Acupuncturist, etc. Name Date of last visit: Address: City: State: Zip Code: Phone # with Area Code: Name Date of last visit: Address: City: State: Zip Code: Phone # with Area Code: Name Date of last visit: Address: City: State: Zip Code: Phone # with Area Code: Please check areas that apply to you Alcohol Emphysema Low Blood Pressure Scarlet Fever # of drinks daily? Excessive Bleeding Mitral Valve Prolapse Seizures Anemia Fainting Pacemaker Smoker Angina Fatigue Easily Nervousness /Depression Snore or gasp for air during sleep Ankle Swelling Glaucoma Osteoarthritis Sleep Apnea Artificial Heart Valve Heart Conditions Periodontal Disease Stomach Problems Artificial Joints, Plates, Screws Heart Lesions Prophylactic antibiotics before cleaning or dental treatment Stroke Asthma Heart Murmur Thyroid Disease Atherosclerosis Heart Surgery Tuberculosis Blood Disease Hepatitis: A B C Radiation (Head / Neck) Ulcers Bruise Easily High Blood Pressure Recreational Drugs, such as marijuana, stimulants, depressants that may have a fatal with local anesthetics or other common dental medications? Venereal Disease Cancer HIV Positive/AIDS Women Only Chemotherapy Hypoglycemia Birth Control Congenital Heart Lesions Jaundice Nursing Diabetes/Prediabetes Kidney Disease Respiratory Problems Pregnant: Delivery Date Dizziness/Fainting Leukemia Rheumatic Fever Drug Addiction Liver Disease Rheumatoid Arthritis Are currently being treated for any of the above conditions? YesNo Which one(s)? If being treated for another condition, please describe: Current Weight: Current Height: Have you gainedor lost weight within the last year? If so, How much? Please check if you have any of the following drug allergies? Aspirin Latex Precodan Please list other allergies. Codeine Anesthetic Penicillin Darvon Nitrous Oxide Antibiotics Erythromycin Sulfa Other Allergies Please check if you have ever taken any of the following drugs Fosamax Didronel Zometa Boniva Phen Fen Aredia Actonel Skelid Biphosphonates Please list ALL medications you currently take. (Prescription & Over The Counter. Attach List if Needed) Please name the pharmacy you use: City: Phone: Are you taking vitamins; food supplements; herbal preparations? Please list. Please feel free to offer any dental or medical information below that would assist us in getting to know you better Sleep Disordered Breathing is highly prevalent in the U.S. population. This brief survey has been quite useful in discovering whether this possibility exists. Using The Epworth Sleepiness Scale of 0 – 3 How likely are you to doze off or fall asleep in the following situations? Sitting and Reading Lying down to rest in the afternoon if conditions permit Watching TV Sitting and talking to someone Sitting inactive in a public place, ie... theater or a meeting Sitting quietly after lunch without alcohol As a passenger in a car for an hour without a break In a car, while stopped for a few minutes in traffic TOTAL SCORE Is there a disease or condition not listed above that you think I should know of? YesNo If Yes, what? I certify the information recorded on this medical & dental form is correct. I understand it is my responsibility to notify The Dental Wellness Center of any changes. I understand that if I withhold information regarding allergies, medical conditions, medications, or supplements, I agree not to hold The Dental Wellness Center or its employees liable in the event of death or injury. Authorization is given for dental treatment to be rendered by the dentist and office staff, and I will assume financial responsibility. Signature Patient: Sign your name below (using your mouse or finger) [signature* history-signature-patient background:#FFFFFF] Date After you hit the "Send" button to submit this form, you will see a confirmation below that the form has been sent. Then click the "Next" button to continue to the next form. FIRST STEP: THEN CLICK NEXT TO CONTINUE: