mcbride@rpmdentistry.com
562.421.3747
Form: Medical Health History

Form: Medical Health History

Provider Information



 













 






 



 


 






 


 






 


 



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  

YesNo





gainedor lost weight within the last year?

Please check if you have any of the following drug allergies?

Aspirin Latex Precodan
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)






Using The Epworth Sleepiness Scale of 0 – 3 How likely are you to doze off or fall asleep in the following situations?

       
   


YesNo


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* history-signature-patient background:#FFFFFF]


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