Welcome to Our PracticePatient Name: (First)MI(Last)Email Address:Gender:MFPhone:mobile:Mailing Address:CityPostal CodeBirthdate: (d/m/y)Insurance Information:Policy Holder:Birthdate of Policy Holder: d/m/yInsurance Company:Group Number:Certificate (ID)NumberSecondary Insurance:Policy Holder:Birthdate of Policy Holder: d/m/yInsurance Company:Group Number:Certificate (ID)NumberMedical History: Indicate which of the following conditions you have or have had. By checking the box, it will indicate a “Yes” response, leave it blank will indicate a “NO” responseMedical History - Part IPre-MedicationAllergy – CodeineAllergy - PenicillinArtificial JointsCancerDizziness/FaintingExcessive BleedingGlaucomaHead InjuryHeart MurmurHepatitis CHivesLiver DiseaseMultiple SclerosisPacemakerRespiratory ProblemsRheumatoid ArthritisSTDThyroid DiseaseTumorsEver Been Hospitalized (illness or injury)TobaccoAlcohol UseMedical History - Part IIAllergy (See Notes)Allergy (Iodine)Allergy (Sulfa)AnemiaAsthmaContraceptive UseEmphysemaExcessive BruisingHard to FreezeHearing DisabledHepatitis AHigh Blood PressureJaundiceLow Blood PressureNervous DisordersBisphosphonate Treatment (Fosamax) – OsteoporosisRheumatic FeverSinus ProblemsTMJUlcersSubject to frequent headachesFemale: Birth controlMedical History - Part IIIAllergy - AspirinAllergy - LatexAllergy - ErythromycinArthritisBlood DiseaseDiabetesEpilepsyGastro-IntestinalHay FeverHeart DiseaseHepatitis BHIV + (AIDS)Kidney DiseaseAnxietyOther (add to notes)Radiation TreatmentRheumatismSkin RashStrokeTuberculosisPresently being treated for other illnessesFemale: Currently PregnantIf any conditions or alerts selected above need further clarification, please describe below:Do you take antibiotic premedication for your dental visits? If yes, please explain.Name of your physician and phone number:What is your estimate of your general health?ExcellentGoodFairPoorList all medications (prescription and non-prescription) including regular does of aspirin:* By signing this form, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and respondedaccordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that Imust notify the practice of any future changes.Signature:Response Date: Send Message