LEE & MELAZZO
4516 Valleydale Road
Birmingham, AL 35242
Phone: 205-991-5343

Patient Health History

	Personal Information
Patient Name:
Legal Name:
Street Address:
City:
State:
Zip:
Patient's Home Number:	- -
Patient's Work Number:	- -
If Child, Lives with (Name):
Daytime Phone Number:	- -
Cell Phone Number:	- -
Email Address:
Patient Birth Date:
Male	Female Child
Single	Married Divocred Separated Widow
Full Time Student? Where? :
Spouse's Name:
Spouse's Phone:

		Medical History Information
Please		Check Yes or No
Yes No	Anemia/Blood Disease	Yes No	Fainting/ Nervous	Yes No	Mitral Valve Prolapse		Allergic to:
Yes No	Arthritis	Yes No	Glaucoma	Yes No	Neck/Head Pain	Yes No	Aspirin
Yes No	Asthma/Hay Fever	Yes No	Heart Trouble	Yes No	Pregnant	Yes No	Codeine
Yes No	Blood Pressure/High	Yes No	Pace Maker	Yes No	Rheu Fever/Murmur	Yes No	Local Anesthesia
Yes No	Blood Pressure/Low	Yes No	Hepatitis/ Liver Disease	Yes No	Stroke	Yes No	Sulfa
Yes No	Cancer/Tx/X-Ray	Yes No	Herpes Virus	Yes No	TB/Lung Disease	Yes No	Penicillin
Yes No	Diabetes	Yes No	HIV Positive/ AIDS	Yes No	TMJ/Clicking Joint	Yes No	Sedative/Tranquilizer
Yes No	Epilepsy/Seizures	Yes No	Joint Replacement	Yes No	Veneral Disease
Yes No	Migraine Headaches	Yes No	Night Sweats	Yes No	Persistent Cough	Yes No	Premedicate
Yes No	Unexplained Fatigue	Yes No	Sinus Trouble	Yes No	Heart Stint	Yes No	Medical Alert
Yes No	Cardiovascular Disease ( heart attack, angina, coronary, insufficiency, coronary occlusion arteriosclerosis)					Yes No	Unexplained Fever/Chills
Yes No	Tobacco Use
Yes No	Are you taking birth control pills?
Yes No	Have you had any serious illness?	If yes:
Yes No	Taking Medications	If yes:
Yes No	Allergic to Medications?	If yes:
Yes No	Have you ever had Periodontal (gum) treatment?	If yes:
Yes No	Have you been out of the country in the last 12 months?	If yes:

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