Medical Dental Building     509 Olive Way, Suite 1414     Seattle, WA 98101     (206) 623-3122
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Roger J. Harper D.D.S,  M.S.D,   Restorative Dentistry

MEDICAL HISTORY FORM

 

Your Name          Email Address

Physician's Name         Phone () -    ext.

Please indicate any of the following conditions which apply to your health status:

Heart trouble, stroke Diabetes
Heart murmur Hepatitis
Heart surgery Ulcers, stomach or intestinal problem
Rheumatic fever Venereal disease, STD
Cardiac pacemaker Glaucoma, eye disorder
Heart valve prosthesis HIV, ARC
High or low blood pressure Autoimmune disease or immunodeficiency
Liver disease, jaundice Sinus trouble
Kidney disease Tuberculosis
Tumor, growth, cancer Emphysema
Thyroid, parathyroid disease Epilepsy, convulsions, fainting
Asthma, hayfever, allergies Joint replacements
Prostrate trouble Arthritis

Please check yes or no to the following:

Have you been hospitalized within the last two years? Yes No
Have you experienced blood anemia, or taken blood thinners? Yes No
Do you wear contact lenses? Yes No
Is there a history of diabetes in your family? Yes No
Are you subject to frequent headaches? Yes No
Are you pregnant? Yes No If "yes" how many months pregnant?
Are you allergic to any medications or drugs? Yes No
Penicillin
Stimulants
Sulfa
Pain medication
Antibiotics
Sedatives
Other (Specify)

Do you have any disease, condition, or problem not listed above that we should be notified of? If so, please explain in the space provided:

Please list any medications you are currently taking, and the dosage:

  Medication Medication

 

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