DR. BRAD SORENSON | DR. LEVI MILLER
1708 S. Clover Drive | MOSES LAKE, WA
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(509) 761-6568
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Patient Health History Update
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First Name
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Last Name
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Date of Birth
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Health History
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Are you currently being treated by a physician?
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Yes
No
If Yes:
Have you ever been hospitalized or had a major operation?
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Yes
No
If Yes:
Are you taking any medications, pills, or drugs?
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Yes
No
If Yes:
Do you like your smile?
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Yes
No
If No:
Do you use tobacco?
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Yes
No
Do you use controlled substances?
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Yes
No
If Yes:
Women: Are you pregnant / Trying to get pregnant?
Yes
No
Nursing?
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No
Taking oral contraceptives?
Yes
No
Are you allergic to any of the following?
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Aspirin
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Yes
No
Local Anesthetics
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Yes
No
Codeine
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Yes
No
Iodine
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Yes
No
Metal
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Yes
No
Latex
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Yes
No
Antibiotics
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Yes
No
If Yes:
Food Allergies
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Yes
No
If Yes:
Other?
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Yes
No
If Yes:
Do you have, or have you had, any of the following?
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AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores / Fever Blisters
Congenital Heart Disorder
Convulsions
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells / Dizziness
Frequent Cough
Frequent Headaches
Glaucoma
Heart Attack / Failure
Heart Murmur
Heart Pacemaker
Heart Trouble / Disease
Sleep Apnea
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain In Jaw Joints
Parathyroid Disease
Psychiatric Care
Snoring
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatism
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach / Intestinal Disease
Stroke
Swelling Of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Have you ever had any serious illnes not listed?
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No
If Yes:
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Date: 9/21/2023