Silvija Dedinac

Patient Name:_____________________ Birthdate:____________________ Cell/Home phone:__________________________Email:________________________________ Home Address:___________________________________________________________________________________ Current Insurance_____________________________________ID#_________________________________________ I consider my health to be (check one):  Excellent  Good  Fair  Poor Do you have or have you had any of the following? Please circle Y for yes or N for no. 1. Y N Heart Disease 25. Y N Liver Disease 2. Y N Hear Murmur/Mitral Valve Prolapse 26. Y N Jaundice 3. Y N Stroke 27. Y N Hepatitis Type 4. Y N Congential Heart Lesions 28. Y N Diabetes 5. Y N Rheumatic Fever 29. Y N Excessive Urination and/or Thirst 6. Y N Pacemaker 30. Y N Infectious Mononucieosis (“Mono”) 7. Y N Stent 31. Y N Herpes 8. Y N Abnormal Blood Pressure 32. Y N Arthritis 9. Y N Anemia 33. Y N Sexually Transmitted/Venereal Diseases 10. Y N Prionged Bieeding Disorder 34. Y N Kidney Disease 39. Y N HIV 11. Y N Tuberculosis or Lung Disease 35. Y N Tumor or Malignancy 40. Y N AIDS 12. Y N Asthma 36. Y N Cancer/Chemotherapy 41. Y N Immune Suppressed Disorder 13. Y N Hay Fever 37. Y N Radiation/Therapy 42. Y N Hearing Loss 14. Y N Sinus Trouble 38. Y N History of Drug Addiction 43. Y N Fainting Spells 15. Y N Epilepsy/Seizures 44. Y N Glaucoma 16. Y N Ulcers 45. Y N History of Emotional or Nervous Disorders 17. Y N Implants/Artificial Joints: Hip-Knee________ Orther________________________________ WOMEN: 18. Y N I smoke or use chewing tobacco. If yes, how much per day?____ How many years?_______ 46. Y N Are you taking birth control medication? 19. Y N I have consumed alcohol within the last 24 hours 47 Y N Are you or could you be pregnant or nusing? 20. Y N I usually take an antibiotic prior to dental threatment. 21. Y N Have you ever taken Fen-Phen or Redux? 22. Y N Do you take or have you ever taken Bisphosphonates (Fosamax Boniva Actonel Aredia Zometa etc.) for Osteoporosis or any other condition? 23. Y N I have had major surgery. Year_________ Type of operation_______________ Year_________ Type of operation________________________ ________________________________________________________________________________________________________________________________ 24. Y N Do you have any other medical problem or medical history NOT listed on this form?____________________________________________________ Are you allergic to any of the following? Please circle Y for yes or N for no 48. Y N Aspirin 49. Y N Ibuprofen 50. Y N Sulfa Drugs/Sulfites/Sulfides 51. Y N Penicilin 52. Y N Codeine 53. Y N Latex Metals Plastics 54. Y N Local Anesthetics (i.e.. Novocain Lidocaine) 55. Y N Other Medications Which ones?____________________________ ______________________________________________________________ Please list all medications you are currently taking: Medicine_______________________Condition________________________ Medicine_______________________Condition________________________ Medicine_______________________Condition________________________ Medicine_______________________Condition________________________ Physician’s Name___________________Phone________________________ Address___________________________Fax__________________________ In the event of an emergency please concat: Name____________________________________________Relationship______________________Phone____________________________ Name____________________________________________Relationship______________________Phone____________________________ Initial medical/dental health reviewed by: X________________________________________/________/______ Doctor’s SignatureDate Periodic medical/dental health reviewed by: X________________________________________/________/______ Doctor’s SignatureDate X________________________________________/________/______ Doctor’s Signature Date X________________________________________/________/______ Doctor’s SignatureDate X________________________________________/________/______ Patient’s SignatureDate X________________________________________/________/______ Patient’s SignatureDate X________________________________________/________/______ Patient’s SignatureDate X________________________________________/________/______ Patient’s SignatureDate