420 N Evergreen Rd # 400, Spokane Valley, WA 99216

Patient Forms
Make A Payment

<
Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.
Birth Date:
   
Have you been under the care of a medical doctor during the past two years? Yes No
If yes, please explain.
Do you take, or have you taken, Phe-n-Fen or Redux? Yes No
Have you ever taken Fosamax, Boniva., Acton el or any other medications containing bisphosphonates? Yes No
Do you use controlled substances? Yes No
 

Please check yes or no to indicate if you have had any of the following:

AIDS/HIV Positive Yes No

Alzheimer's Disease Yes No

Anaphylaxis Yes No

Anemia Yes No

Angina Yes No

Arhritis/Gout Yes No

Artificial Heart Valve Yes No

Artificial Joint Yes No

Asthma Yes No

Blood Disease Yes No

Blood Transfusion Yes No

Breathing Problems Yes No

Bruise Easily Yes No

Cancer Yes No

Chemotherapy Yes No

Chest Pains Yes No

Cold Sores/Fever Blisters Yes No

Congenital Heart Disorder Yes No

Convulsions Yes No

Cortisone Medicine Yes No

Diabetes Yes No

Drug Addiction Yes No

Easily Winded Yes No

Emphysema Yes No

Epilepsy or Seizures Yes No

Excessive Bleeding Yes No
Excessive Thirst Yes No

Fainting Spells/Dizziness Yes No

Frequent Cough Yes No

Frequent Diarrhea Yes No

Frequent Headaches Yes No

Genital Herpes Yes No

Glaucoma Yes No

Hay Fever Yes No

Heart Attack/Failure Yes No

Heart Murmur Yes No

Heart Pacemaker Yes No

Heart Trouble/Disease Yes No

Hemophilia Yes No

Hepatitis A Yes No

Hepatitis B or C Yes No

Herpes Yes No

High Blood Pressure Yes No

High Cholesterol Yes No

Hives or Rash Yes No

Hypoglycemia Yes No

Irregular Heartbeat Yes No

Kidney Problems Yes No

Leukemia Yes No

Liver Disease Yes No

Low Blood Pressure Yes No

Lung Disease Yes No
Mitral Valve Prolapse Yes No

Osteoporosis Yes No

Pain in Jaw Joints Yes No

Parathyroid Disease Yes No

Psychiatric Care Yes No

Radiation Treatments Yes No

Recent Weight Loss Yes No

Renal Dialysis Yes No

Rheumatic Fever Yes No

Rheumatism Yes No

Scarlet Fever Yes No

Shingles Yes No

Sickle Cell Disease Yes No

Sinus Trouble Yes No

Spina Bifida Yes No

Stomach/Intestinal Disease Yes No

Stroke Yes No

Swelling of Limbs Yes No

Thyroid Disease Yes No

Tonsillitis Yes No

Tuberculosis Yes No

Tumors or Growths Yes No

Ulcers Yes No

Venereal Disease Yes No

Yellow Jaundice Yes No

 

Allergies:

NONE
Amoxicillin
Aspirin
Barbiturates
Codeine
Epinephrine
Erythromycin
Keflex
Iodine
Latex
Lortab
Morphine
Penicillin
Sulfa
Tetracycline
Other
 
List medications currently taking (name and dosage):
Do you have or have you had any disease, condition or problem not listed above? Yes No
If yes, please explain
Do you need to take any antibiotics (pre-medicate) before any dental appointment? Yes No
If yes, please explain
Have you been in the hospital or had a serious illness within the past five years? Yes No
If yes, please explain
 

Women:

Are you pregnant? Yes No
Are you nursing? Yes No
Do you take Birth Control Pills? Yes No
 
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing icnorrect information can be dangerous to my (or patients) health. It is my responsibility to inform the dental office of any changes in medical status.
Your request has been sent -- we will be in contact with you shortly.
There was an error! Please phone our office.
Request an Appointment