Initial Visit Application

Health and Medical History

Patient name:

DOB:

Age:

Sex:

Height:

Weight:

Marital Status:

Employer:
How long:

E-mail address:

Country:

Street address:

City:

State:

Zip Code:

Do you smoke?

How much if yes?

For how long?

Do you chew tobacco?

How much if yes?

For how long?

Are you now under the care of a physician?

For what conditions

Have you even been hospitalized for illness or surgery?

Were there any problems with this?

Have you had a general anesthetic in a hospital?

Where there any problems with this?

Has any family member had an adverse reaction to anesthesia?

Do you take any drugs(prescription or non-prescription?

Please list names and dosages

Do you have or have you ever had:

Allergy to any drug or medication?	yes no
If so, please list drug name and reaction or problem
Adverse ration to any anesthetic or anesthesia?	yes no
Heart disease or cardiovascular disease?	yes no
Heart Attack?	yes no
Angina?	yes no
High Blood Pressure	yes no
Low blood pressure?	yes no
Heart attack?	yes no
Rheumatic fever?	yes no
Congenital heart defects or problems?	yes no
History of heart disease in your family?	yes no
Artificial heart valves, artificial joints, or other implants?	yes no
Diseases or surgery of eyes, ears, nose, or throat?	yes no
Special problems of head, neck, or jaws?	yes no
Do you wear contact lenses?	yes no
Do you have TMJ or jaw joint problems?	yes no
Breathing problems?	yes no
Lung or pulmonary disease?	yes no
Asthma?	yes no
Aspirin allergy?	yes no
Unusual bleeding problems?	yes no
Blood disorder?	yes no
Blood transfusion?	yes no
Immune system suppression or compromise?	yes no
Any medication that affects the immune system?	yes no
Frequent infections?	yes no
Anemia?	yes no
Liver disease?	yes no
Hepatitis?	yes no
Jaundice or yellowing of the skin or eyes?	yes no
Diabetes?	yes no
Low blood sugar?	yes no
Ulcers?	yes no
Intestinal disease?	yes no
Kidney disease?	yes no
Thyroid disease?	yes no
Seizures or epilepsy?	yes no
Steroid or cortisone treatment?	yes no
Arthritis?	yes no
Cancer treatment?	yes no
Chemical dependency?	yes no
Psychiatric care?	yes no
Family history of inherited diseases?	yes no

Any disease, condition, or problem not mentioned above that the doctor should know about?

Are you or may you be pregnant?

Are you breast feeding an infant?

Are you taking birth control pills?

Initial Visit Application

Health and Medical History

Do you have or have you ever had:

Press the button below to submit your information: