PATIENT HEALTH HISTORY INFORMATION 18.0 Date: Patient Name (Last, First, MI): Birth Date %PatientNameLast%, %PatientNameFirst% %PatientNameMiddle% (MM/DD/YYYY) Physician / Medical Clinic Name: Last Physical Exam: Select the appropriate answer Have you been under the care of a medical doctor in the past two years? No Yes Have you been a patient in the hospital during the past two years? No Yes Have you had any excessive bleeding requiring special treatment? No Yes Do you smoke or use tobacco products? No Yes ALLERGIES - Select all that apply Aspirin Allergy Codeine Allergy Erythromycin Allergy Hay Fever Latex Allergy Penicillin Allergy Sulfa Allergy Other Allergy: Have you taken any medications or drugs in the past two years? No Yes Are you taking any vitamins / herbal supplements / holistic remedies? No Yes Have you ever, or are you currently taking any medications for osteoporosis or bone disease? No Yes MEDICATIONS - Please list any medications you are currently taking including vitamins and dietary supplements Please check this box if your physician or previous dentist recommended you take antibiotics prior to your dental treatment. Please check this box if you are taking additional medications not listed here. Bring a list to your appointment.