Patient Informations

Last Name

First Name

Middle Name

Birthday

Gender Male Female

Civil Status Single Married Widowed

Job

Home Address

Company

Insurance

Contact Number

Weight (kgs)

Height (cm)

PreviousBP

CurrentBP

Temperature

 

For Minors

Parent's / Guardian's Name

Occupation

Health History

YES NO   Are you in good health now?

NO YES   Have you been hospitalized or had serious illness in the last three years?

NO YES   Have you been hospitalized or had serious illness in the last three years?

NO YES   For women, are you pregnant?

NO YES   Are you taking medications?

If yes, list down the medications

Do you have any of the following?

NO YES	Allergy	NO YES	Anemia
NO YES	Asthma	NO YES	Arthritis
NO YES	Bleeding	NO YES	Blood Transfusion
NO YES	Cancer	NO YES	Convulsion
NO YES	Diabetes	NO YES	Ear Problem
NO YES	Epilepsy	NO YES	Fainting
NO YES	HIV	NO YES	Heart Ailment
NO YES	Hemophilia	NO YES	Hepatitis
NO YES	Jaundice	NO YES	Kidney Disease
NO YES	Mental Disorder	NO YES	Neurological Problems
NO YES	Nose Throat Disorder	NO YES	Rheumatic Fever
NO YES	Skin Disease	NO YES	Tuberculosis

 

Dental History

Previous Dentist

Procedure Done

Last Dental Visit

 

Medical History

Name of Physician

Office Address

Office Number

Specialty (if applicable)