Medical History Form – Dr. Woodmansee

1Progress - 60% Completed

2Progress - 90% Completed

3Progress - 95% Completed

4Progress - 100% Completed

Patient Name*
First Last
Sex*
- Male
- Female
Date of Birth*
Age*
Height*
Weight*
Phone*
Patient's Email*
Patient's Address*
City*
State*
Zip*
Would you like us to send your prescriptions electronically to your pharmacy to be ready for pick up on your way home after surgery?*
- Yes
- No
Pharmacy Name:*
Pharmacy Address:*
Pharmacy Zip Code*
Are you completing this form for someone else?*
- No, I am the patient.
- Yes
Relationship to Patient*
INSURANCE AND DENTIST INFORMATION
Do you Have a Dentist?*
- Yes
- No
Dentist name/office*
Do you have Dental Insurance?*
- Yes
- No
Subscriber Name*
First Last
Subscriber Date of Birth*
Insurance Company Name*
Subscriber or Member ID #*
Insurance Company Phone #*
Insurance Group Number (if applicable)
Employer (if applicable)
MEDICAL INFORMATION
Are you taking any prescription or non-prescription medications?*
- Yes
- No
Please list and explain
Medication Reason for using medication
Do you remember the date of your last physical examination?*
- Yes
- No
Date:
Are you presently under the care of a physician?*
- Yes
- No
For what condition?*
Have you ever been hospitalized or had a serious illness/operation*
- Yes
- No
For what condition?*
Family history of anesthetic or anesthesia complications*
- Yes
- No
Please explain:*
Allergic reaction to any drug, food, or substance*
- Yes
- No
List*
Cause Reaction
Have you had abnormal bleeding*
- Yes
- No
Please explain:*
Do you have any blood disorder such as anemia, hemophilia, sickle cell anemia, HIV*
- Yes
- No
Please explain:*
Have you ever had treatment for a tumor or cancer*
- Yes
- No
Please explain:*
Have you ever had radiation therapy to the head, neck, or jaws*
- Yes
- No
Please explain:*
Are you taking or have you ever taken Bisphosphonates medications for osteoporosis or chemotherapy such as Fosamax, Actonel, Boniva, Aredia, or Zometa*
- Yes
- No
Please explain:*

FEMALES
Are you pregnant or trying to become pregnant
- Yes
- No
Please specify*
Are you nursing?
- Yes
- No
Please specify*
Are you taking oral contraceptives/ hormonal therapy
- Yes
- No
Please specify*
Do you have menstrual problems
- Yes
- No
Please explain*

Anything else you would like to tell your doctor?
- Yes
- No
Please explain*
I HAVE READ AND UNDERSTAND THE ABOVE QUESTIONS. ALL QUESTIONS I HAD ABOUT THIS FORM HAVE BEEN ANSWERED. I UNDERSTAND IT IS MY RESPONSIBILITY TO FILL OUT THE FORM CORRECTLY AND COMPLETELY.
Patient’s Signature (or Legal Guardian) to be signed physically in office: ___________________________________________________
Name
First Last
Email
This field is for validation purposes and should be left unchanged.

Medication	Reason for using medication

Cause	Reaction

INSURANCE AND DENTIST INFORMATION

MEDICAL INFORMATION

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING DISEASES, PROBLEMS, OR CONDITIONS

FEMALES