Patterson Family Dentistry

Select Your Primary Office

Name

Family Physician

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?

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?

Signature

Patient Medical Information Form