bp test form

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Patient Information

Birthdate:
Spouse Birthdate:

Responsible Party / Billing Information

Spouse Birthdate:

Insurance Information

Do you have dual coverage?
  Yes     No

Medical History

How would you describe your overall health?
When was your last physical?
Have you been hospitalized under a physician's care in the last two years?
  Yes     No
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic.)
Aspirin
Codeine
Valium
Iodine
Sulfa Drugs
Tetracycline
Penicillin
Erythromycin
Novocaine
Xylocaine
Nitrous Oxide
Latex
Have you ever had any of the following? (Please check all that apply.)
Arthritis or Gout
Artificial Joint
Asthma
Allergies
Bleeding Problem or Anemia
Blood Disease
Blood Transfusion
Bruise Easily
Cancer
Cold Sores
Congenital Heart Problems
Currently Pregnant
Diabetes
Dizziness or Fainting
Drub/Alcohol Addiction
Eating Disorder
Emphysema
Epilepsy or Seizures
Fever Blisters
Frequent Thirst
Frequent Urination
Glaucoma
Heart Attack or Stroke
Heart Murmur
Heart Trouble
Heart Valve or Pacemaker
Hepatitis (A)
Hepatitis (B)
Hepatitis (C)
Herpes
Low Blood Pressure
High Blood Pressure
HIV-AIDS-ARC
Hypoglycemia
Jaw Joint Pain
Kidney or Liver Disease
Lung Disease
Psychiatric Care
Radiantion/Chemotherapy
Rheumatic Fever
Sinus Problems
Thyroid Problems
Tuberculosis
Tumor or Growth
Ulcers or G.I. Problems
Use Tobacco
X-ray/Chemotherapy
Have you ever been given antibiotics before dental treatment?
  Yes     No
Have you recently consumed alcohol?
  Yes     No
Have you recently used recreational drugs?
  Yes     No
Recreational use combinded with local anesthesia may cause a life threatening emergency.

Dental History

When was your last dental visit?
When were your last dental x-rays?
When was your last cleaning?
Have you avoided regular dental care?
  Yes     No
Do you feel you have active decay?
  Yes     No
Do you experience frequent bad breath?
  Yes     No
Do you feel you have gum disease?
  Yes     No
Have you ever had gum treatments?
  Yes     No
How often do you brush?
How often do you floss?
How often do you use other aids?
Are you happy with the appearance of your teeth?
  Yes     No
Would you like your teeth to be whiter?
  Yes     No
How would you rate your previous dental expeience?

Nearest Relative

Name of nearest relative not living with you?
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