General Patient UpdatePATIENT INFORMATIONFirst Name * Last Name * MI If you are completing this form for another person, what is your relationship to that person? Your Name Relationship Home Phone Cell Phone E-mail Today’s Date * As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws.MEDICAL INFORMATIONAllergies (check all that apply)Local anestheticsAspirinPenicillin or other antibioticsBarbiturates, sedatives, or sleeping pillsSulfa drugsCodeine or other narcoticsMetalsLatex (rubber)IodineHay fever/seasonalAnimalsFood/OtherIf yes, please specify Do you use controlled substances (drugs)?YesNoDo you use tobacco (smoking, snuff, chew, bidis)?YesNoIf so, how interested are you in stopping? VerySomewhatNot InterestedDo you drink alcoholic beverages?YesNoIf yes, how much alcohol did you drink in the last 24 hours? Joint Replacement: Have you ever had an orthopedic total joint replacement?YesNoIf yes, date If yes, have you had any complications?YesNoHave you had a serious illness, operation or been hospitalized in the past 5 years?YesNoIf yes, what was the illness or problem? Are you taking or have you recently taken any prescription or over the counter medicine(s)?YesNoDo you take any blood thinners?YesNoDo you take aspirin on a regular basis?YesNoIf yes, please list all, including vitamins, natural or herbal preparations and/or diet supplements: Are you currently under the care of a physician?YesNoAre you in good health?YesNoHas there been any change in your general health within the past year?YesNoIf yes, what condition is being treated? Physician Name Phone Address/City/State/Zip Date of last physical exam Women OnlyPregnant?YesNoNumber of weeks Taking birth control pills or hormonal replacements?YesNoNursing?YesNoPHARMACY INFORMATIONPharmacy Name Pharmacy Phone Pharmacy Address Has a physician recommended that you take antibiotics prior to your treatment?YesNoDo you have any disease, condition, or problem not listed above that we should know about?YesNoIf yes, please explain SIGNATUREComments I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.I confirm the information provided is accurate and I consent to electronic signature. I understand this document may be signed electronically for the purposes of validity, enforceability, and admissibility.Name of Patient/Legal Guardian * Date * Electronic Signature (type full name) *
