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Medical History Form
Medical Form
First Name: *

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D.O.B. *

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Cell Phone:

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Address

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Social Security Number

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Weight

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Relationship

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Name of dental insurance

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2. Has there been any change in your general health within the last year?

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4. Are you now under the care of a physician?

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5. The name and address of my physician(s) is:

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If so, what was the illness or problem?

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a. Do you take Aspirin on a regular basis?

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Please list any other medlclne(s)

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a. Damaged heart valves or artificial heart valves including heart murmur or rheumatic heart disease?

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b. 1. Do you have chest pain upon exertion?

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b. 3. Do your ankles swell?

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b. 5. Do you have a cardiac pacemaker?

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d. Sinus trouble

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f. Hay fever

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h. Persistent diarrhea or recent weight loss

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j. Hepatitis, jaundice or liver disease

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I. Thyroid problems

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n. Arthritis or painful swollen joints

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p. Kidney trouble

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r. Persistent cough or cough that produces blood

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t. Low blood pressure

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v. Epilepsy or other neurological disease

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x. Cancer

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z. History of alcohol or drug abuse

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a. Have you ever required a blood transfusion?

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11. Have you been treated for a tumor or growth?

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a. Local anesthetics

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c. Sulfa drugs

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e. Barbiturates, sedatives, or sleeping pills

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g. Iodine

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i. Latex

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13. Do you smoke?

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14. Do you use recreational drugs?

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16. Are you wearing contact lenses?

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18. Do you have an. artificial hip or other joint replacement?

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19. Have you had any serious trouble associated with any previous dental treatment?

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20. Do you have any disease, condition, or problem not listed above that you think I should know about?

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Women

22. Are you nursing?

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I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Last name: *

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Home Phone: *

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E-Mail: *

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Occupation

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Height

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Emergency Contact Person

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Refered By

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1. Are you in good health?

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3. My last physical examination was on:

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If so, What is the condition being treated?

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6. Have you had any serious illness, operations, or been hospitalized in the past 5 years?

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7. Are you taking any medicine(s) including non-prescription medicine?

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b. Are you taking blood thinners?

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8. Do you have or have you had any of the following diseases or problems?

b. Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosderosis, stroke)?

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b. 2. Are you ever short of breath after mild exercise or when lying down?

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b. 4. Do you have inborn heart defects?

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c. Allergy

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e. Asthma

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g. Fainting spells or seizures

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i. Diabetes

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k. AIDS or HIV infection

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m. Respiratory problems, emphysema, bronchitis, etc.

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o. Stomach ulcer or hyperacidity

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q. Tuberculosis

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s. Persistent swollen glands in neck

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u. Sexually transmitted disease

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w. Problems with mental health

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y. Problems of the immune system

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9. Have you had abnormal bleeding?

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10. Do you have any blood disorder such as anemia?

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12. Are you allergic or have you had a reaction to:

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b. Penicillin

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d. Antibiotics

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f. Aspirin

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h. Codeine or other narcotics

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j. Other

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a. How much per week?

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15. How much alcohol do you consume in a week?

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17. Are you wearing removable dental appliances?

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If yes, date of placement

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If so, explain

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If so, explain

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21. Are you pregnant?

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23. Are you taking birth control pills?

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Type your name

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Promt Service - Dr is very professional and receptive to patient needs and concerns. Dental Assistant was excellent!
I have and will continue to refer friends to your practice!
Appointment on time and the entire staff was friendly, professional, and great to work with....... as always!!!!!!!!!!!!!!!!!!!!!!!
The group provides excellent service. Waiting room time is minimal. Staff is Friendly and efficient. Dental professionals do an excellent job.
I have been availing myself of the group for years. O don't think unless referred I would go anywhere else.
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