Medical History Form- NY Implant Dentistry

Health History
Name*

Patient's First NamePatient's Last Name
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
High blood pressure (hypertension)Irregular heart beat, pacemakerChest pain (Angina)Heart attack (MI)Heart murmur, Mitral valve prolapseProsthetic heart valveHeart surgery (bypass, transplant, stent)None of the aboveOther
AnemiaBleeding disorderBone marrow or stem cell transplantBlood transfusionLeukemia, blood cancer, lymphoma, multiple myelomaNone of the aboveOther
DiabetesThyroidProstate problemsAdrenal disorderCorticosteroid therapyNone of the aboveOther
If yes, type:
hyperhypo
AsthmaEmphysema, bronchitisPneumoniaTuberculosisNone of the aboveOther
HepatitisCirrhosisUlcer(s)Irritable bowlCrohn’s or ulcerative colitisTransplant: liver, kidneyHeart burn (reflux)None of the aboveOther
Allergy to food, metals or jewelryHIV or AIDSLupusSjogren’s syndromeNone of the aboveOther
Alzheimer’s disease or other dementiaDepression, phobia or severe anxiety disorderSeizure/ epilepsyHeadaches, frequent or severeStroke (CVA)Degenerative disorders or paralysis (Parkinson’s, MS, Cerebral Palsy, etc.)None of the aboveOther
DialysisSyphilis, gonorrhea, herpesNone of the aboveOther
ANY history of cancerRadiationChemotherapySurgeryNone of the aboveOther
Explain:
Explain:
Artificial jointDegenerative arthritisRheumatoid arthritisOsteoporosisTreated with drugs for osteoporosisNone of the aboveOther
Rash/ hives/ soresSkin pathologyNone of the aboveOther
If yes, explain:
I am pregnant or possibly pregnantI am nursingPost-menopauseContraceptiveNone of the aboveOther
Have you been hospitalized during the past 2 years? Please explain:*
Physician*
Tel*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any health problems that need further clarification?*
Medications List Please :
Signature
The above medical history has been reviewed with me and to the best of my knowledge the recordings are complete and accurate. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Signature Of Patient, Parent Or Guardian*

Clear
Date*

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Date
Should be Empty:

Health History

Signature