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Patient Health Assessment
Patient Health Assessment
Greenwood Family Dental
2021-02-04T16:29:39+00:00
Patient Information Form
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Health Assessment
Health Assessment 2021
Patient Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
1. Have you seen a medical doctor during the past two years?
*
Yes
No
2. Have you taken any medicine or drugs during the past two years?
*
Yes
No
3. Are you allergic to or made sick by penicillin, aspirin, codeine, or any other drugs or medications?
*
Yes
No
4. Have you ever had any excessive bleeding requiring special treatment?
*
Yes
No
5. When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest or shortness of breath, or because you are very tired?
*
Yes
No
6. Do you ever wake up from sleep short of breath?
*
Yes
No
7. WOMEN: Are you pregnant?
Yes
No
8. Are you currently taking any medications?
Yes
No
List of Medications:
Please list each on a separate line.
9. Name of Physician
*
Physician's Phone Number
10. Please check any of the following which you have had or have at present:
Heart Failure
Yes
Anemia
Yes
Arthritis
Yes
Heart Disease or Attack
Yes
Stroke
Yes
Rheumatism
Yes
Angina Pectoris
Yes
Kidney Trouble
Yes
Cortisone Medicine
Yes
High Blood Pressure
Yes
Ulcers
Yes
Glaucoma
Yes
Heart Murmur
Yes
Emphysema
Yes
Pain in Jaw Joints
Yes
Rheumatic Fever
Yes
Tuberculosis (TB)
Yes
AIDS
Yes
Congenital Heart Lesions
Yes
Asthma
Yes
Hepatitis A (infectious)
Yes
Scarlet Fever
Yes
Scarlet Fever
Yes
Allergies or Hives
Yes
Hepatitis B (serum)
Yes
Artificial Heart Valve
Yes
Diabetes
Yes
Liver Disease
Yes
Heart Pacemaker
Yes
Thyroid Disease
Yes
Yellow Jaundice
Yes
Heart Surgery
Yes
X-ray or Cobalt Treatmemt
Yes
Blood Transfusion
Yes
Artificial Joint
Yes
Chemotherapy
Yes
Hemophilia
Yes
Cold Sores
Yes
Epilepsy or Seizures
Yes
Dizzy Spells
Yes
Sickle Cell Disease
Yes
Bruise Easily
Yes
Sinus Trouble
Yes
Dr. Signature
Date
Notes:
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