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Dr. Donald W. Hogan D.D.S
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Medical Health History
Medical Health History
Medical Health History
.
Salutation:
Mr.
Mrs.
Ms.
Miss.
Name:
Name:
*
First
Last
Nick Name:
*
Date of Birth:
Date of Birth:
*
/
MM
/
DD
YYYY
Personal Physician:
Personal Physician:
*
First
Last
Allergies:
*
Yes
No
Drug Sensitivities:
*
Yes
No
Asthma:
*
Yes
No
Tuberculosis:
*
Yes
No
Breathing Problems:
*
Yes
No
Hepatitis:
*
Yes
No
Liver Disease:
*
Yes
No
Ulcers (Presently or Previously):
*
Yes
No
GI Disturbances:
*
Yes
No
Are You Pregnant?
*
Yes
No
Rheumatic Fever:
*
Yes
No
Heart Murmur:
*
Yes
No
High Blood Pressure:
*
Yes
No
Diabetes:
*
Yes
No
Kidney Disease:
*
Yes
No
Seizure Disorder:
*
Yes
No
Vertigo:
*
Yes
No
Fainting or Dizzy Spells:
*
Yes
No
Cancer/Tumor:
*
Yes
No
Radiation Therapy:
*
Yes
No
Problems with Anesthesia:
*
Yes
No
HIV or AIDS:
*
Yes
No
Explanations for YES Responses:
List of Medications:
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