1 Patient Information Date SS/HIC/Patient ID # Name Address City ...

Health History
Physician’s Name
Date of Last visit
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?”
These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin
(fenfluramine and Redux (dexfenfluramine). YES NO
Place a mark on yes or no to indicate if you have had any of the
following:
AIDS/HIV
YES NO GLAUCOMA YES NO SPECIAL DIET YES NO
ARTHRITIS, RHEUMATISM YES HANDICAPS OR
STOMACH PROBLEMS YES
NO
DISABILITIES YES NO
NO
ARTIFICIAL HEART VALVESYES HEADACHES YES NO STROKE
YES
NO
NO
HEART MURMUR
YES
ARTIFICIAL JOINTS YES NO
NO
SWOLLEN FEET
ASTHMA
YES NO HEART PROBLEMS YES NO
OR ANKLES YES NO
BACK PROBLEMS
YES HEPATITIS TYPE ____ YES SWOLLEN NECK GLANDS YES
NO
NO
NO
BLEEDING ABNORMALLY, WITH
HERPES
YES THYROID PROBLEMS YES NO
NO
TONSILLITIS YES NO
EXTRACTIONS OR SURGERYYES
HIGH BLOOD PRESSURE YES TUBERCULOSIS
YES
NO
NO
NO
BLOOD DISEASE
YES JAUNDICE YES NO TUMOR/GROWTH ON HEAD
NO
JAW PAIN YES NO
OR NECK YES NO
CANCER
YES KIDNEY DISEASE
YES ULCER YES NO
NO
NO
VENEREAL DISEASE YES NO
CHEMICAL DEPENDENCY YES LIVER DISEASE
YES WEIGHT LOSS,
NO
NO
UNEXPLAINED YES NO
CHEMOTHERAPY
YES LOW BLOOD PRESSURE YES
Do you wear contact lenses?
NO
NO
YES NO
CIRCULATORY PROBLEM YES
MITRAL VALVE PROLAPSEYES
Have you ever taken
NO
NO
NERVOUS PROBLEMS
BISPHOSPHONATES
YES NO
CONGENITAL HEART
PACEMAKER
or any Bone Building drug?
YES NO
LESIONS
YES
YES NO
PSYCHIATRIC CARE YES NO
NO
RADIATION TREATMENT YES
CONGENITAL HEART
If yes, please list:
NO
DEFECT
YES RESPIRATORY DISEASE YES
NO
NO
WOMEN: CONVULSIONS
YES RHEUMATIC FEVER YES NO
Are you pregnant? YES NO Due Date Are you nursing? YES NO
Taking birth NO control pills? YES NO SCARLET FEVER
YES
CORTISONE TREATMENTS YES
NO
MEDICATIONS: NO
SHORTESS OF BREATH YES
NO
List COUGH, any medications PERSISTENT you are currently taking and the correlating diagnosis:
SINUS TROUBLE
YES
OR BLOODY YES NO
NO
DIABETES
YES NO
SKIN RASH YES NO
EMPHYSEMA YES NO
EPILEPSY
YES
NO
Pharmacy FAINTING Name OR DIZZINESS YES
Phone ( )
ALLERGIES: NO
Aspirin Codeine Iodine Latex Local Anesthetic Sulfa
Barbiturates (sleeping Pills) Penicillin Other
Authorization and Release. To the best of my knowledge, the questions on this f orm hav e been accurately answered. I understand that prov iding incorrect inf ormation can be
dangerous to my self and or my child’s health. It is my responsibility to inf orm the dental of f ice of any changes in my or my child’s medical status. I also authorize the dental staf f to
perf orm the necessary dental serv ices my child may need. I also authorize the dentist to release any inf ormation including the diagnosis and the records of treatment or examination
rendered to my self or my child during the period of such care to third party pay ers and /or other health practitioners. I authorize and request my insurance company to pay directly to
the Dentist or Dentist’s group insurance benef its other wise pay able to me. I understand that my insurance carrier may pay less than the actual bill f or serv ices. I agree to be
responsible f or pay ment of all serv ices rendered on my behalf or my dependents.
Signature of patient or responsible party if a minor
Date
Signature of Dentist/Doctor’s Review
Date
New Town Dental Arts 4939 Courthouse Street — Williamsburg, Virginia 23188 — 757/259-0741 · Fax 757/259-0718
www.newtowndentalarts.net
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