Patient Medical History

PATIENT'S NAME
DATE OF BIRTH
MM slash DD slash YYYY
ARE YOU IN GOOD HEALTH
- YES
- NO
HAVE THERE BEEN ANY CHANGES IN YOUR GENERAL HEALTH WITHIN THE PAST YEAR
- YES
- NO
DATE OF YOUR LAST PHYSICAL EXAM:
MM slash DD slash YYYY
PHYSICIAN'S NAME
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
PHONE NO.
ARE YOU NOW UNDER THE CARE OF A PHYSICIAN
- YES
- NO
HAVE YOU EVER BEEN HOSPITALIZED FOR ANY SURGICAL OPERATION OR SERIOUS ILLNESS
- YES
- NO
PLEASE EXPLAIN.
ARE YOU TAKING ANY MEDICINE(S) INCLUDING NON-PRESCRIPTION MEDICINE
- YES
- NO
IF YES, WHAT MEDICINE($) ARE YOU TAKING
HAVE YOU HAD ANY ABNORMAL BLEEDING
- YES
- NO
DO YOU BRUISE EASILY
- YES
- NO
HAVE YOU EVER REQUIRED A BLOOD TRANSFUSION
- YES
- NO
HAVE YOU HAD A RECENT WEIGHT LOSS
- YES
- NO
HAVE YOU EVER TAKEN FEN-PHEN/REDUX
- YES
- NO
DO YOU USE TOBACCO
- YES
- NO
DO YOU OR HAVE YOU USED CONTROLLED SUBSTANCES
- YES
- NO
ARE YOU WEARING CONTACT LENSES
- YES
- NO
DO YOU HAVE A PERSISTENT COUGH OR THROAT CLEARING NOT ASSOCIATED WITH A KNOWN ILLNESS (LASTING MORE THAN 3 WEEKS)
- YES
- NO
DO YOU HAVE ANY DISEASE, CONDITION OR PROBLEM NOT LISTED ABOVE THAT YOU THINK I SHOULD KNOW ABOUT
- YES
- NO
WOMEN ONLY:
ARE YOU PREGNANT OR THINK YOU MAY BE PREGNANT
- YES
- NO
ARE YOU NURSING
- YES
- NO
ARE YOU TAKING BIRTH CONTROL PILLS
- YES
- NO

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What Patients Think About Our Service

Average Rating: 4.9 Reviews: 89

Ken Robertson, DMD

5409 Maryland Way, Suite 210 Brentwood, Tennessee 37027

WOMEN ONLY: