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Submit by Email Patient Name ( check ) P Mr. Ms. Mrs. Dr. A T I E N T M E D I C A L H ……………………………………………………………………………… ( check Home Address …………………………………………………… I S T O R Y city Date of Birth ……………………………………………………. preferred contact # ) Home Phone ……………………………………………………. apartment # …………………………………………………… Mobile Phone ……………………………………………………. ……………… state Social Security # ……………………………………………………. …………… street Print Form Work Phone …………………………………. ………… zip ext E-mail Address ……………………………………………………. Emergency Contact: …...…...………..……..…….………………… …………………….…….. Contact Phone ……………………………………………………. relationship Patient Medical History Physician: ………………………………………………………… ……………… Office Phone ……………………………………………………. date of last exam yes no yes no 5. Are you wearing contact lenses? 6. Women Only: Are you pregnant or think you may be pregnant? Are you nursing? Are you taking birth control pills? 1. Are you under medical treatment now? 2. Have you ever been hospitalized for any surgical operation or serious illness? 3. Do you use tobacco? 4. Do you use alcohol, cocaine, or other recreational drugs? (circle) 7. Are you allergic to or have you had any reaction to the following? yes no yes no Penicillin Local Anesthetics (e.g.Novacaine) Antibiotics Sulfa Drugs 8. Do you, or have you had any of the following? yes no High Blood Pressure Heart Attack Rheumatic Fever Swollen Ankles Fainting/Seizures Asthma Low Blood Pressure Epilepsy/Convulsions Leukemia Diabetes Kidney Disease AIDS or HIV Infection Thyroid Problem Heart Disease Cardiac Pacemaker Heart Murmur Angina Frequently Tired Anemia Emphysema Cancer Arthritis Hepatitis / Jaundice Sexually Trans. Disease Stomach Trouble/Ulcers Chest Pain Easily Winded Stroke Hay Fever/Allergies Tuberculosis Radiation Therapy Glaucoma Recent Weight Loss Liver Disease Heart Trouble Respiratory Problems Other yes yes no Aspirin Latex Products Iodine Metals Sedatives Other …………………… Medications 9. Are you taking or have you taken the following medication? Fen-Phen (dietary supplement for weight loss) Actonel Boniva Fosamax Skelid Didronel Aredia Zometa Bonefos yes 10. Have you had the following surgery(s)? Joint Replacements Pins, Screws or Posts Heart Surgery Pace Makers Organ Transplants 11. Are you taking any medication(s) including non-prescription and herbal medicine? If yes, what medication(s) are you taking? (please list below) no no …………………………………………………………………………………………………… …………………………………………………………………………………………………… for staff only: …………………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………………….. _________________ ( dentist ) ____ __________ ( date ) ___________ ( staff ) If other, please list I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. …………………….…………………… ………………………………………… X ......................................... patient signature DERRICK M. CHAN, DDS & ASSOCIATES 1828 CLEMENT STREET SAN FRANCISCO, CA 94121 ....................... today’s date 415 . 221 . 5200 Revised 12/07 - All Rights Reserved
