General Patient Update PATIENT INFORMATION First 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 INFORMATION Allergies (check all that apply) Local anestheticsAspirinPenicillin or other antibioticsBarbiturates, sedatives, or sleeping pillsSulfa drugsCodeine or other narcoticsMetalsLatex (rubber)IodineHay fever/seasonalAnimalsFood/Other If yes, please specify Do you use controlled substances (drugs)? YesNo Do you use tobacco (smoking, snuff, chew, bidis)? YesNo If so, how interested are you in stopping? VerySomewhatNot Interested Do you drink alcoholic beverages? YesNo If yes, how much alcohol did you drink in the last 24 hours? Joint Replacement: Have you ever had an orthopedic total joint replacement? YesNo If yes, date If yes, have you had any complications? YesNo Have you had a serious illness, operation or been hospitalized in the past 5 years? YesNo If yes, what was the illness or problem? Are you taking or have you recently taken any prescription or over the counter medicine(s)? YesNo Do you take any blood thinners? YesNo Do you take aspirin on a regular basis? YesNo If yes, please list all, including vitamins, natural or herbal preparations and/or diet supplements: Are you currently under the care of a physician? YesNo Are you in good health? YesNo Has there been any change in your general health within the past year? YesNo If yes, what condition is being treated? Physician Name Phone Address/City/State/Zip Date of last physical exam Women Only Pregnant? YesNo Number of weeks Taking birth control pills or hormonal replacements? YesNo Nursing? YesNo PHARMACY INFORMATION Pharmacy Name Pharmacy Phone Pharmacy Address Has a physician recommended that you take antibiotics prior to your treatment? YesNo Do you have any disease, condition, or problem not listed above that we should know about? YesNo If yes, please explain SIGNATURE Comments 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) *
