Annual Medical History Update

Patient First Name:
Patient Last Name:
Health Care Card Number:

Dentist: Please Select Dr. Andrew Doig Dr. Ryan Gallagher

1. Are you in Good Health
Yes No

2. Have you had an unusual reaction to drugs/medications? To what? i.e. Penicillin

Yes No

3. Is your physician treating you now?

Yes No

Reason?

4. Are you taking any medication? (prescription or over the counter)

Yes No
Please list
Pharmacy contact info

5. Do you smoke or use tobacco products?

Yes No

6. Do you use recreational medical marijuana?

Yes No

7. Do you have any allergies?

Yes No

Please list

8. Do you experience shortness of breath?

Yes No

9. Have you gained or lost excessive weight recently?

Yes No

10. Do you have heart disease or murmur? Heart Attack?

Yes No
If so, when?

11. Are your ankles often swollen?

Yes No

12. Have you ever had radiation treatment?

Yes No

13. For women only, are you any of the following?:

Pregnant

Nursing

HRT

14. Have you had any of the following? (check all that apply):

Heart trouble
High Blood Pressure
Rheumatic Fever
Blood disorders
Diabetes
Epilepsy
Thyroid trouble
Kidney trouble
Cancer
HIV/AIDS
Asthma
Tuberculosis
Pic Line
Anemia
STD
Hepatitis
Liver trouble

Other:

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