Patient Medical Information-Roanoke
Many medical conditions that may not seem to have any affect on dental procedures often do. So please fill out completely. Thank You!
Please provide first, last and middle initial. Thank You!
Family Physician Phone #
When was your last visit to a physician and why?
When was your last dental visit? What was done?
Present complaint, concern or request
Has the patient ever had an allergic reaction to any drugs?
If yes to the previous question, please list.
Has the patient ever had a reaction to an anesthetic injection?
Has the patient ever had excessive or prolonged bleeding?
Has the patient had slow healing of a wound or incision?
Please check any of the following the patient has ever had.
High/low blood pressure
Facial muscle pain
Has the patient ever had Hepatitis, and what type?
List and/or describe any other general health conditions that might have a bearing on dental care.
Is the patient pregnant?
If pregnant, what is the Due Date?
Does the patient take Birth Control Pills?
List any recent medications and the reason for taking each medication.
Has the patient ever been exposed to HIV? If yes, please explain.
Any other blood conditions?
Do Not Fill This Out