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Online Health Form	Date * Patient Full Name (Last, First, Middle) * Gender * Male Female Home Address (Street) * (City, State, Zip Code) * Home Number * Cell Number * Date of Birth xx/xx/xxxx * Referred By Email Address Social Security number * Marital Status Single Married Divorced Widowed Name of Business City, State Zip Code Occupation Work Phone Number (EXT) Spouse's Name DOB Emergency Contact Name * Emergency Contact Address * Emergency Contact Telephone # * Height * Weight * GENERAL HEALTH: * Excellent Good Fair Poor PHYSICIAN NAME * PHYSICIAN ADDRESS * DATE OF LAST PHYSICAL * PHARMACY NAME/ PHONE NUMBER If your currently in the care of Physician, REASON? LIST MEDICATIONS: MEDICATION LIST CONTINUED List any Herbal Medications: Are you taking medications for Osteoporosis? * YES NO Are you taking Aspirin? * Yes NO Are you allergic to: Antibiotics Codeine Aspirin Local Anesthetics Allergic to any other medications not listed Reason for Hospitalizations and Dates: Hosptalizatons continued: Have you had any radiological xrays in the past 5 years * Yes No Have you had any Blood Transfusion? * Yes No Are you currently trying to modify your weight? * Yes No Have you experienced any sudden weight changes? * Yes No Do you take any weight reduction medications? * Yes No Do you smoke? * Yes No How many Packs Per Day? Do you consume Alcohol? Infrequent Occassional Daily Are you Pregnant? Yes No How far along? Do you experience pre menstrual syndrome? Yes No Do you take Birth contol pills Yes No Check if you have had Chest Pains Heart Disease Rheumatic Fever Kidney Problems Stroke Hormonal Problems Tuberculosis Epilepsy Cancer/Leukemia Sickle Cell Anemia Prosthetic Heart Valve Jaundice AIDS/HIV Allergies/Hives Arthritis Persistent Cough Sexually Transmitted Disease Skin Disease Unexplained Fevers Enlarged Lymph Nodes Persistent Diarrhea Fatigue Check if you have had Fainting Spells Hypertension Congenital Heart Defect Heart Murmur Thyroid Problems Ulcers Diabetes Anemic Psychiatric Problems Glaucoma Bruise Easily Asthma/Hay Fever Sinus Trouble Excessive Thirst /Urination Prolonged Bleeding Genetic Problems IBS Prolonged Sore Throat Night Sweats Blue/Red Lesions Prosthetic Joints Have you ever been tested for Hepatitis? * YES NO Have you ever been diagnosed with or told you were a carrier of Hepatitis A,B,C or NONA/NONB? * YES NO Do you have a history of cold sores, fever blisters or canker sores? * YES NO Are you being treated with immunosuppressive drugs? * YES NO Have you ever used drugs for recreational purposes? * YES NO When was you last Dental visit? * Have you ever had any problems associated with Previous dental treatment? (line 1) * (line 2) How often do you brush your teeth? * How often do you floss? * Please describe any dental issues you may be experiencing? Line 1 Line 2 Line 3 Signature (SIGN USING MOUSE) * Name of Card Holder Credit Card number Expiration Date Billing Zip Code Signature ( SIGN USING MOUSE) The undersigned hereby authorizes the Doctor to perform all necessary diagnostic procedures deemed appropriate to make a thorough diagnosis of the patients dental or oral facial needs including Xrays, study models, photographs, medications and the use of local anesthetic Signature (SIGN USING MOUSE) * Date * Signature (Sign using mouse) Date Name