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Eaglesoft Medical History 2024

Patient Information

First Name *

Last Name *

Middle Initial

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

- If none, please write none

What is your Primary physician name and phone number?

Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux?

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Are you on a special diet?

YesNo

Do you use tobacco?

YesNo

Do you use controlled substances?

Women: Are you...

Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?

Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalMetalLocal Anesthetics

Other?

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Yes No

Hemophilia

Yes No

Radiation Treatments

Yes No

Alzheimer's Disease

Yes No

Diabetes

Yes No

Hepatitis A

Yes No

Anaphylaxis

Yes No

Drug Addiction

Yes No

Hepatitis B or C

Yes No

Renal Dialysis

Yes No

Anemia

Yes No

Herpes

Yes No

Angina

Yes No

Emphysema

Yes No

High Blood Pressure

Yes No

Rheumatism

Yes No

Arthritis/Gout

Yes No

Epilepsy or Seizures

Yes No

High Cholesterol

Yes No

Artificial Heart Valve

Yes No

Excessive Bleeding

Yes No

Shingles

Yes No

Artificial Joint

Yes No

Excessive Thirst

Yes No

Hypoglycemia

Yes No

Asthma

Yes No

Fainting Spells/Dizziness

Yes No

Sinus Trouble

Yes No

Blood Disease

Yes No

Kidney Problems

Yes No

Blood Transfusion

Yes No

Leukemia

Yes No

Stomach/Intestinal Disease

Yes No

Breathing Problems

Yes No

Frequent Headaches

Yes No

Liver Disease

Yes No

Stroke

Yes No

Low Blood Pressure

Yes No

Cancer

Yes No

Lung Disease

Yes No

Thyroid Disease

Yes No

Chemotherapy

Yes No

Mitral Valve Prolapse

Yes No

Chest Pains

Yes No

Heart Attack/Failure

Yes No

Osteoporosis

Yes No

Tuberculosis

Yes No

Cold Sores/Fever Blisters

Yes No

Heart Murmur

Yes No

Pain in Jaw Joints

Yes No

Tumors or Growths

Yes No

Congenital Heart Disorder

Yes No

Heart Pacemaker

Yes No

Parathyroid Disease

Yes No

Ulcers

Yes No

Convulsions

Yes No

Psychiatric Care

Yes No

Venereal Disease

Yes No

Special needs

Yes No

Do you snore

Yes No

Have you ever had any serious illness not listed above? -if not, please write none

Please list your emergency contact and phone number?

Comments

Patient, Parent or Guardian

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Name *

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I consent to use Electronic Records and Signatures

Relationship to patient *

Name *

Thank you for contacting us. We look forward to assisting you.

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Office hours

Monday 09:00 AM - 06:00 PM
Tuesday 09:00 AM - 01:00 PM
Wednesday 09:00 AM - 06:00 PM
Thursday 09:00 AM - 06:00 PM
Friday 09:00 AM - 01:00 PM
Saturday Closed
Sunday Closed
Closed between 1:00 - 3:00 on Monday, Wednesday and Thursday

Get in touch

Thank you! We will connect with you shortly.

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contact info

17401 Greenfield Rd.
Detroit, MI 48235

Phone Number:
313-395-0088

Fax:
313-837-5550

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Eaglesoft Medical History 2024

Eaglesoft Medical History 2024

Patient Information

Women: Are you...

Are you allergic to any of the following?

Do you have, or have you had, any of the following?

Comments

Patient, Parent or Guardian

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