* = required field Personal Information *Name: Date of Birth: / / Street Address: City: State: Zip Code: Day Phone: *Email: Medical Information Do you have excessive bleeding from cuts? Physician: Last physical exam: Are you under a physician's care now? yes no Reason: Are you pregnant? yes no Are you taking any drugs/medication/pills now? yes no If yes, what? Have you ever had an allergic or adverse response from any drugs? yes no Comments Have you a history of: Abnormal blood pressure yes no Heart disease yes no T.B. yes no Anemia yes no Arthritis yes no Rheumatic fever yes no Radiation treatment yes no Diabetes yes no Hepatitis yes no Heart murmur yes no Any artificial joint prosthesis or heart valves? yes no Are you now, or have you ever received, treatment for alcohol or drug abuse? yes no Have you had skin grafts? yes no
Copyright © 1999 by Lawrence W. Hagen, II, D.D.S. 4998 Glenway Avenue • Cincinnati, Ohio 45238 Phone: (513) 251-5500 • Fax: (513) 251-0687 Email: hagendds@aol.comHagen DDS Home This site hosted by Electronic Art
