Fill Out Form Patient Health History Update

Patient Health History Update Fields marked with * are required

First Name *

Last Name *

Date of Birth *

Health History Fields marked with * are required

Are you currently being treated by a physician? * Yes No

If Yes:

Have you ever been hospitalized or had a major operation? * Yes No

If Yes:

Are you taking any medications, pills, or drugs? * Yes No

If Yes:

Do you like your smile? * Yes No

If No:

Do you use tobacco? * Yes No

Do you use controlled substances? * Yes No

If Yes:

Women: Are you pregnant / Trying to get pregnant? Yes No

Nursing? Yes No

Taking oral contraceptives? Yes No

Are you allergic to any of the following? Fields marked with * are required

Aspirin * Yes No

Local Anesthetics * Yes No

Codeine * Yes No

Iodine * Yes No

Metal * Yes No

Latex * Yes No

Antibiotics * Yes No

If Yes:

Food Allergies * Yes No

If Yes:

Other? * Yes No

If Yes:

Do you have, or have you had, any of the following? Fields marked with * are required

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? * Yes No

If Yes:

Comments

Signature Fields marked with * are required

Date: 9/21/2023

DR. BRAD SORENSON | DR. LEVI MILLER
1708 S. Clover Drive | MOSES LAKE, WA

SCHEDULE NOW
(509) 761-6568

DR. BRAD SORENSON | DR. LEVI MILLER 1708 S. Clover Drive | MOSES LAKE, WA

SCHEDULE NOW (509) 761-6568

DR. BRAD SORENSON | DR. LEVI MILLER
1708 S. Clover Drive | MOSES LAKE, WA

SCHEDULE NOW
(509) 761-6568