Patient Registration And Health History Form Page 2
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1
2
3
4Health History
Are you currently under the care of a physician?
Yes
No
H. Infectious Diseases
1.
Hepatitis (A, B, or other)
Yes
No
Physician’s Name ______________________________
2.
AIDS, HIV
Yes
No
Address ______________________________________
Phone # _____________________________________
I. Radiation History
1.
Have you had radiation therapy?
Yes
No
Do you now, or have you ever had;
A. Cardiovascular System
J. Medication
1.
High or low blood pressure
Yes
No
Are you taking any of the following?
2.
Heart attack or Heart Surgery
Yes
No
1.
Antibiotics or sulfa drugs
Yes
No
3.
Heart murmur
Yes
No
2.
Anticoagulants (blood thinners)
Yes
No
4.
Congenital heart disease
Yes
No
3.
Medicine for high blood pressure.
Yes
No
5.
Chest pain upon exertion (angina)
Yes
No
4.
Cortisone (steroids)
Yes
No
6.
Rheumatic heart disease or fever
Yes
No
5.
Anti-depressants
Yes
No
7.
Stroke
Yes
No
6.
Antihistamines
Yes
No
8.
Other _____________________________________
7.
Aspirin on a regular basis?
Yes
No
8.
Insulin or other anti-diabetic meds
Yes
No
B. Nervous System
9.
Digitalis or other heart medications
Yes
No
1.
Epilepsy, convulsions, seizures,
10. Nitroglycerin
Yes
No
or fainting.
Yes
No
11. Chemotherapy
Yes
No
2.
Neuritis, neuralgia, or numbness
Yes
No
12. History of diet pills (Fen-phen, etc.)
Yes
No
13. Inhaler, prescription or OTC
Yes
No
C. Respiratory System
14. Medication for Erectile Dysfunction
Yes
No
1.
Tuberculosis
Yes
No
15. Please list other medications:
2.
Sinus trouble, hay fever, allergies
Yes
No
_________________________________________________________
3.
Pneumonia, asthma, or emphysema
Yes
No
_________________________________________________________
4.
History of smoking
Yes
No
K. Allergies
D. Genitourinary and Gastrointestinal Systems
Are you allergic to or have you had a reaction to:
1.
Kidney disease
Yes
No
1.
Penicillin or other antibiotics
Yes
No
2.
Stomach or intestinal problems
Yes
No
2.
Sulfa
Yes
No
3.
Liver disease, jaundice, or hepatitis
Yes
No
3.
Local anesthetics (Novocaine, etc.)
Yes
No
4.
Ulcers, reflux disease
Yes
No
4.
Latex
Yes
No
5.
Eating disorders
Yes
No
5.
Aspirin
Yes
No
6.
Codeine
Yes
No
E. Endocrine System
L. Women
1.
Diabetes
Yes
No
1.
Are you pregnant?
Yes
No
2.
Thyroid disease
Yes
No
2.
History of breast cancer
Yes
No
3.
Using birth control?
Yes
No
F. Blood-Lymphatic
1.
Blood disorder or anemia
Yes
No
Do you have any disease, condition, or health problem not previously
2.
Abnormal bleeding
Yes
No
listed?
Yes
No
_________________________________________________________
G. Bones and Joints
1.
Osteo- or rheumatoid arthritis
Yes
No
_________________________________________________________
2.
Joint replacement
Yes
No
3.
Back, neck, or jaw injury
Yes
No
My signature certifies that the information provided is complete and accurate. I agree to inform PDX Endodontics of any changes
in my medications or health prior to any future treatment.
_____________________________________________________________
_______________________________
Signature (patient / guardian):
Date
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
My signature certifies that I have reviewed a copy of this office’s Notice of Privacy Practices.
□
If you wish to receive a copy of our notice of Privacy Practices, please check here
_____________________________________________________________
_______________________________
Signature (patient / guardian)
Date
For Dr.s use only
: Pulse _______________ BP _________________
Dr. Initials ____________________
FOR OFFICE USE ONLY
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
□ Individual refused to sign
□ Emergency situation prevented / prohibited obtaining acknowledgement
□ Communication barriers prohibited obtaining acknowledgement
□ Other
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