Island Dental
Center of Summerlin
Michael J. Tomita, D.D.S. & Stan S. Askew, D.D.S.
Patient Name: -----------------------------
Yes
No
Patient Account #: ------------------------
Medical Alert:
------------------------------
1.
Have
you been under the care of a medical doctor within
the past two years? ---------------------------
If yes, for what?
Physician's name: -------------------------
Physician's phone: ------------------------
Address:
City:
State:
Zip:
2.
Have
you taken any medications over the past two years?
------------------------------------------------
3.
Are
you taking any medications, drugs or pills now?
-------------------------------------------------------
If yes, please list name and dosage.
4.
Have
you taken prescription medications for weight loss
(diet pills)?
-------------------------------------
If yes, did you take any of the following:
Yes
No
Fen-Phen
Yes
No
Pondimen
Yes
No
Redux
If
yes to any of the above, did you have a medical
exam for heart issues?
-----------------------------
5.
Are
you aware of having an allergic (or adverse)
reaction to any medication or substance?
------------
If yes, please list:
6.
Have
you been a patient in a hospital during the past
five years?
---------------------------------------
7.
Please indicate which of the following you have
had, or have at present. Check "Yes" or "No"
for each item listed below.
Heart (surgery, attack, disease)
Yes
No
Ulcers
Yes
No
Hepatitis A,B,C
Yes
No
Chest Pain
Yes
No
Diabetes
Yes
No
Venereal Disease
Yes
Congenital Heart Disease
Yes
No
Thyroid Problem
Yes
No
AIDS
Yes
Heart Murmur
Yes
No
Glaucoma
Yes
No
HIV Positive
Yes
High Blood Pressure
Yes
No
Contact Lenses
Yes
No
Cold Sore/Fever Blisters
Yes
Mitral Valve Prolapse
Yes
No
Emphysema
Yes
No
Blood Transfusion
Yes
Artificial Heart Valve
Yes
No
Chronic Cough
Yes
No
Hemophilia
Yes
Heart Pacemaker
Yes
No
Tuberculosis
Yes
No
Sickle Cell Disease
Yes
Rheumatic Fever
Yes
No
Asthma
Yes
No
Bruise Easily
Yes
Arthritis/Rheumatism
Yes
No
Hay Fever
Yes
No
Liver Disease
Yes
Cortisone Medication
Yes
No
Latex Sensitivity
Yes
No
Yellow Jaundice
Yes
Swollen Ankles
Yes
No
Allergy or Hives
Yes
No
Neurological Disorders
Yes
Stroke
Yes
No
Sinus Trouble
Yes
No
Epilepsy or Seizures
Yes
Diet (Special/Restricted)
Yes
No
Radiation Therapy
Yes
No
Fainting or Dizzy Spells
Yes
Artificial Joints (hip, knee, etc.)
Yes
No
Chemotherapy
Yes
No
Nervous/Anxious
Yes
Kidney Trouble
Yes
No
Tumors
Yes
No
Psychiatric/
Psychological Care
Yes
8.
Have
you ever had a reaction to any type of jewelry?
------------------------------------------------------
9.
Have
you lost or gained more than 10 pounds in the last
year?
------------------------------------------
10
Do
you have or have you had any disease, condition,
or problem not listed?
---------------------------
If yes, please list:
11.
Women, are you:
Pregnant?
Yes
Months:
No
Nursing?
Yes
No
Taking birth control pills?
Yes
No
I
understand the above information is necessary to
provide me with dental care in a safe and
efficient manner. I have answered all questions to
the best of my knowledge. Should further
information be needed, you have my permission to
ask the respective health care provider or agency,
who may release such information to you. I will
notify the doctor of change in my health or
medication.
NOTE:
Please print this form, fill out and either mail
it to our office, fax it to our office or bring it in
when you come in for your appointment. Remember
to fill out all 5 forms.
