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Andrew Koenigsberg, DDS
Robert Rawdin, D.D.S., F.A.C.P.
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Samantha Rawdin, DMD
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Frank Orlando, DDS
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Medical History Form
Download the printable New Patient PDF form.
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Name
*
First
Last
Date of Birth
*
Sex
*
Male
Female
Are you under a physician's care now?
*
Yes
No
Please explain
Have you ever been hospitalized or had a major operation?
*
Yes
No
Please explain
Have you ever had a serious head or neck injury?
*
Yes
No
Please explain
Are you taking any medication, pills or drugs?
*
Yes
No
List all pills, medications or drugs that you are currently taking
Do you take or have you taken Phen-Fen or Redux
*
Yes
No
List any additional details about Phen-Fen or Redux
Are you on a special Diet
*
Yes
No
What type of diet and what is the reason?
Do you use tobacco?
*
Yes
No
Amount and frequency you use tobacco products
Do you use controlled substances?
*
Yes
No
Pregnancy
Are you pregnant or trying to get pregnant?
*
Yes
No
Are you taking oral contraceptives
*
Yes
No
Are you nursing
*
Yes
No
Your Sleep
Do you wake up tired in the morning
*
Yes
No
Have you ever fallen asleep while driving
*
Yes
No
Do you snore
*
Yes
No
Allergies
Place a check next to any of the following materials and medications to which you are allergic.
Aspirin
Penicillin
Codeine
Acrylic
Latex
Local Anesthetics
Other
List any other allergies
Other Conditions
Do you have, or have you had any of the following?
Conditions
AIDS/HIV positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Arificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting/Dizziness
Conditions
Fainting/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives/Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Conditions
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed above
*
Yes
No
Explain any serious coniditions or illnesses
Any additional comments?
