Confidential Patient Information – II 


(Please Print Legibly) 

Patient Name: _____________________________ Initial Date: ____________________________________________________ 
Updated: __________________________________________________ 
Updated: __________________________________________________ 
Updated: __________________________________________________ 
Updated: __________________________________________________ 

HEALTH INFORMATION 

Personal Physician Name: _____________________________________________________________________________________ 
Personal Physician Address: ____________________________________________________________________________________ 

YES NO 
 1. Have you been hospitalized within the past 2 years? For what? ____________________________ 
 2. Are you currently being treated by a physician? For what? ________________________________ 
 3. Are you currently taking any medicines or drugs? What? _________________________________ 

 4. Have you ever received counseling for excessive use of alcohol and/or prescription drugs? 
 5. Are you allergic to any drugs? What? __________________________________________________ 
 6. Have you ever had a skin rash or other reaction to metal jewelry? To What? _______________ 
 7. Are you allergic to any metals? What? _________________________________________________ 
 8. Do you bleed excessively upon injury? 
 9. Are you pregnant? 
 10. Have you ever been involved with dental/medical legal activity? 


CIRCLE ANY OF THE FOLLOWING CONDITIONS THAT YOU HAVE HAD OR NOW HAVE 

A. AIDS 
F. Epilepsy K. High Blood Pressure P. Rheumatic Fever 
B. Arthritis 
G. Glaucoma L. Jaundice Q. SexuallyTransmitted Diseases 
C. Asthma 
H. Heart Murmur M. Kidney Problems 
R. Stroke 
D. Cancer 
I. Heart Problem* N. Low Blood Pressure 
S. Tuberculosis 
E. Diabetes 
J. Hepatitis O. Nervous Breakdown 
or Psychiatric Therapy T. Other Diseases* 
*If you circled either I or T describe condition: ___________________________________________________________________ 

PERSON TO BE CONTACTED IN CASE OF EMERGENCY (OTHER THAN RELATIVE) 

Name: ______________________________________________________________________________________________________ 
Address: ____________________________________________________________________________________________________ 
Telephone: (Home) __________________________________ (Work) _______________________________________________ 

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