2424 Webster Street Berkeley, California 94705
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Home
About Us
Services
Patient Info
New Patient Online Forms
Post-Operative Instructions
Dental Emergencies
Patient Education
FAQ’s
Review
Appointments
Medical History
Home
Medical History
Patient First Name:
MI:
Last Name:
Birth Date :
Sex :
Male
Female
General Health Questions
1. Have you any serious illness, operations or hospitalizations?
Yes
No
2. Are you under a physician's care at this time?
Yes
No
Name, address and phone # of physican
Do you have or did you ever have any of the following
Cardiovascular Health
3. High Blood pressure ?
Yes
No
4. Angina or heart attack ?
Yes
No
5. Chest pain on physical exertion ?
Yes
No
6. Coronary artery blockage or treatment (bypass, stent, etc.)
Yes
No
7. Heart valve problem or replacement
Yes
No
8. Heart murmur
Yes
No
9. Heart disease , problem or treatment
Yes
No
10. Rheumatic fever
Yes
No
11. Past use of Fen-Phen
Yes
No
12. Irregular heart beat or pacemaker
Yes
No
13. Difficulty breathing when lying down
Yes
No
14. Stroke
Yes
No
15. Low blood pressure
Yes
No
Respiratory Health
16. Asthma
Yes
No
17. Emphysema or respiratory problems
Yes
No
18. Chronic sinus problems
Yes
No
19. Tuberculosis or persistent cough
Yes
No
Endocrine/Blood/Immune Health
20. Diabetes
Yes
No
21. Frequent Thirst or frequent urination
Yes
No
22. Thyroid problems
Yes
No
23. Abnormal bleeding, bruise easily
Yes
No
24. Hemophilia
Yes
No
25. Anemia/blood disease
Yes
No
26. Cancer
Yes
No
27. Radiation therapy/chemotherapy
Yes
No
28. HIV infection/AIDS
Yes
No
29. Cold sores/canker sores
Yes
No
30. Organ transplant
Yes
No
31. Blood transfusion
Yes
No
Muscular-Skeletal/CNS/Mental Health
32. Join replacement
Yes
No
33. Arthtritis
Yes
No
34. Osteoporosis
Yes
No
35. Fainting spells or dizziness
Yes
No
36. Seizures
Yes
No
37. Numbness or muscle weakness
Yes
No
38. Multiple sclerosis
Yes
No
39. Mental retardation
Yes
No
40. Dementia/Alzheimer's disease
Yes
No
41. Anxiety/Nervousness
Yes
No
42. Mental health treatment
Yes
No
Gastro-Intestinal/ Genito-Urinary Health
43. Hepatitis (A, B, C or other)
Yes
No
44. Liver disease
Yes
No
45. Kidney disease/dialysis
Yes
No
46. Stomach trouble/ulcers
Yes
No
47. Sexually transmitted disease
Yes
No
Medication Allergies and Other Allergies
48. Penicillin or other antibiotics
Yes
No
49. Sulfa drugs
Yes
No
50. Dental antesthetic
Yes
No
51. Aspirin
Yes
No
52. Codeine/narcotics
Yes
No
53. Iodine
Yes
No
54. Latex products
Yes
No
55. Metals/nickels/jewelry
Yes
No
56. Other
Yes
No
Females Only
57. Are you pregnant?
Yes
No
58. Are you nursing now?
Yes
No
59. Do you take birth control pills?
Yes
No
Medications
60. Are you taking any prescription medications, over the counter medications or herbal medicines?
Yes
No
If so, please list them and dose taken:
61. Do you or have you used bisphosphonate medication (Fosomax, Actonel, Boniva, Skelid, Didronel, Aredia, Zometa, Bonefos)?
Yes
No
Social
62. Do you use tobacco?
Yes
No
Quantity
Per Day
63. Do you use alcohol?
Yes
No
Quantity
Per Day
Per Week
64. Do you use recreational drugs?
Yes
No
Quantity
Per Day
65. Do you have any other medical conditions not already listed above?
Yes
No
Please list:
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