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Meet The Team
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Broomfield
Thornton
Westminster
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Invisalign For Adults
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Virtual Care
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Patient Portal
Contact Us
About Us
Meet Dr. Stoll
Meet The Team
Before and After
Areas Served
Broomfield
Thornton
Westminster
Treatments
Invisalign
How Invisalign Works
Invisalign For Teens
Invisalign For Adults
Cosmetic Adjustments for Adults
Braces
Braces for Teens
Braces For Adults
Early Treatment
Resources
Blog
Comfort Instructions
New Patient Info
Technology
Virtual Care
3D Printer
3D Scanner
X-Rays
Retainers for Life
Patient Portal
Contact Us
(303) 450-2211
Medical History Information Form
Patient Name
Phone
Email
Is patient in good health?
Yes
No
Does patient have any history of illness?
Yes
No
Please briefly describe
Please choose any of the following that the patient was treated for:
None
Abnormal Bleeding
Anemia
Arthritis/Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Blood Transfusion
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Defect
Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
Difficulty Breathing
Drug/Alcohol Abuse
Epilepsy
Emphysema
Fainting
Fever Blisters/Herpes
Glaucoma
Headaches
Heart Attack
Heart Surgery
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
High/Low Blood Sugar
HIV/AIDS
Hospitalized for Any Reason
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shingles
Shortness of Breath
Sickle Cell Disease/Traits
Sinus Problems
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
Does patient have tendency toward:
Colds
Sore Throats
Ear Infections
Headaches
Has patient ever been exposed to:
Herpes
AIDS
Hepatitis
Have tonsils and/or adenoids been removed?
Yes
No
List drugs or medications being taken:
List any allergies or drug sensitivities
