EdmundM. Caruso, D.MD.
PATIENTNAME
Birth·Date
_
Although dental pemonneI primarily treat the 8I8a In and around your mouth. ·your mouth is 8 part of your entire body. Health problemS that you may
baYe, or medication Ulat you may be 1aking, could have an impodantintenelationshfp
with the dentisby you wiIIl8C8ive. Thank you for anerMHfrig.the
following questions.
Ale you under a physIcfan's
C81e nfNI?
Have you ever been hospIaIized or had a major operation?
•.•
youeverhadaserfoushead
or neck inJmy?
Ate you taking any medic:Idions. pills. ordnlga-l
. Do you take, or ba¥e you taken, Phen-Fen orRedux?
Are you on a spedaJ diet?
Do you use tobacco?
_._-
! PregnantlTryingtogetpregnant?O
YesO
;0 Aspirin
0 Penicfllin
\0 Other
Ifyee, please explain:
~ .-- .' _. - - ...•.....
.-.-,-.~---.-
0 CodeIne
-- .--~-
'
0 Ya 0 No
0 Yes 0 No.
~-
Q YesQ
0 Y-O
0 YesO
; AnaphylaxIs
; AnemIa
i
0 YesO
a Yesa
! AI1IfIdaI HeaJtVaive
0 VesQ
0 y-o
:.Altlllclal Jolnt
: Asthma
No
No
No
a y-a
0
0 YesO
, Blood TransfUIIon
B19Sthing Problem
a v-a
No
No
Q y_Q
No
0 y-O
BIIStflJa 0 YesO
No
No
t Bruise EasIly
: cancer
a VesO No
; ChernOIheIapy
!
No
No
No
No
VasO No
. Blood DIsease
~.Chest Pains
COld SoresIFever
No
0 y-O No
0 YesO No
AngIna
l ArltlrltlSlGout.
l
, CongenlIaI Heart D!sorderOY-O No
! Convulsions
Q YesO No
,
_
_
-:-_
0 Yes 0 No
-- - .. _._.-
"''''''-'-'~
_
••••
_
~.",
__
._,._
•••••.•
-
-_...
-
..
a
0 Yes Q
Q v_Q
~._
• ~,,_.
.'
•
.--'-'
--. -.,-_ .._._-_
-.. -
_.
-,
_ ..
Y-O
'"
'
~
'~".--"
0 y-O
0 VaO
Q YesO No
0 yesQ No
Q
Leukemia
UverDisease
Low Blood Pmsswe
Lung DIsease
y-a No
0 No
.
..
------ ~-.•..
-
~
--
-.--"-
Renal DJa¥IiS
Rheuma1IcFENer
0 YesO
0 YesO
Rl1eumalism
ScaIIetFever
Q Y_Q
No :.
No :
No i
Q Y_Q
No :
0 YesO
0 YesQ
No :
No :
Q YaO
No :
0 Yes 0 No
vesO
Q YesO No
stroke
YesO No ..
0 y-O No
0 v_O No
Q y- 0 No
y-o No
Q YaO
y-a
No
No
RecentWeightLoas
..• _ ••••
- .. ,--.--
0 VesO No
Q YesO
._
0 YesQ
Q
• ' __
'p' •••
'
_ ••••••
_
No
Swelling oflJrnbS
ThyroId DiSeaSe
0 Yes0 No
0 Yes 0 No
Tonsillitis
TubeR:ulosl8
Q Yes Q No
TumcnorGrowIhs
0 YesONo
UIcef8
Venareal DIseaSe
.•.•
_~._...
No
No
• _
_
•• "
_.
_
.H.',
_.
'P'
~
•••••••
_
••
__
••
~'
••
-_~._
.-.-
•••
-.
'-'-~'
-----------------------------------------------------------------
To the best of. my knoWledge, th$ questions on ttIis form have been accwateIy answered. I undeIstand that providing incorrect illfonnation can be
dangerous to my (or patienfs) beaHh. It is my responsibility to Infonn the denial Gffice of any changes fnmedical SIaIus.
SIGNATURE OF PATIENT, PARENT. orOUARDlAtl
DATE
;
Q YaO
_
•__
:
0 YaO
0 Yes ONo
0 YesO No
VelloW
JaundICe
:
I
:
No :
If yes. pIease.expIaIn:
•••• _
.
SpIna 8111da
StomachJIntes\lnaIDiseaseO
0 Ves0 No
Yes
---
- ..~.------,--.--..-.
_
ShIngles
Sickle Cell Disease
SInuS
Trouble
0 Yes0 No
MltmlVaJveProIapseQ
PaIn in Jaw Joints
No
No
ParathyroId DIsease Q
PsychIaIrIccare
Q VaO No
Radlalion TI881mentSO YesO No
No
--._,
0 vaO No
0 y-o NO
IneguIar Heartbeat
KIdney Problems
_--. ""'"'-'''
No
0 UJcaI AnesIhetics
-.-
"'--
Nursing? 0
-'
0 Latex
H"rv8Sor Rasl'l
~1ycemIa
No
No
Q YesQ No
•. , __
,-'"
High Blood Plesstne
0
Heart Pace Maker
HeartTroublelDisease
----
No
Hepatlti&A
HepaliUsBorC
Hetpes
ExcessIveT1llrst
0 YesQ No
FaIntIng SpeIIaIDIzzinesQ v-O No
Frequent Cougb
Q v-O No
FreqiJeIltDiantlea
VesO No
FrequentHeadadles 0 YesO No
GenIIaIHerpes
0 YasO No
Glaucoma
Q YesQ No
Hay Fever
0 v-O No
HeartAUacklFailwe
0 Y_Q No
HeartMuTmur
YasO
".
Hemophilia
No
YesQ No
Q V_Q No
0 vesO No
0 YesO No
EpBepay or 5elzuI'es
ExcessI\leBJeedIng
.
-.
-
0 v-O
CoItIsoneMedlcfnlt
Diabetes
DrugAddiction
EaalIyWinded
Emphysema
__• ~
'-
0 Metal
-.. ..
_
Have you euer had any serious iftness notlisfBd above?O
Comments:
_
If yes, please expIain:,
,-Do you have, or have you had. anyoftJtefollowfng? "'''-'AlDSIHIV PosItive
: AIzheImet"s Disease
_
0 Ves 0 No··
0 AayRc
- ..
------------
Iryes, please expJain:
Taklngoral contraceptives?
0
No
,.. --.......•... -.-.-.-.-.-- ..,,~.-.- - .. .......•........ ~'Ar8 you altelgicto any offhe following? ..
.
-,
If yes. pIea$e expIain:
If yes, please ecpIain:,,.,;.
0 Yes 0 No
0 v-O No
Doyou use c:ontroIIed substanCes? 0 Yes 0 NO
- --_.-._ ..•...................•....... _.. -. '-'- -.- _.._.._.--
'-Women: Are you.-
-.~
..
0 Ves 0 No
_
:
~
;