MEDICAL HISTORY
Patient Name :
Date of Birth :
Are you under a physician's care now?
Yes
No
If yes, please explain:
Have you ever been hospitalized or had a major operation?
Yes
No
If yes, please explain:
Have you ever had a serious head or neck injury?
Yes
No
If yes, please explain:
Are you taking any medications, pills or drugs?
Yes
No
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?
Yes
No
If yes, please explain:
Are you on special diet?
Yes
No
If yes, please explain:
Do you use tobacco?
Yes
No
If yes, please explain:
Do you use controlled substances?
Yes
No
If yes, please explain:
Women: Are you
Pregnant/Trying to get pregnant?
Yes
No
Taking oral contraceptives?
Yes
No
Nursing?
Yes
No
Are you allergic to any of the following:
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Other
If yes, please explain:
Do you have, or have you had any of the following?
AIDS/HIV Positive
Yes
No
Hemophilia
Yes
No
Alzheimer's Disease
Yes
No
Hepatitis A
Yes
No
Anaphylaxis
Yes
No
Hepatitis B or C
Yes
No
Anemia
Yes
No
Herpes
Yes
No
Angina
Yes
No
High Blood Pressure
Yes
No
Arthritis/Gout
Yes
No
Hives or Rash
Yes
No
Artificial Heart Valve
Yes
No
Hypoglycemia
Yes
No
Artificial Joint
Yes
No
Irregular Heartbeat
Yes
No
Asthma
Yes
No
Kidney Problems
Yes
No
Blood Disease
Yes
No
Leukemia
Yes
No
Blood Transfusion
Yes
No
Liver Disease
Yes
No
Breathing Problem
Yes
No
Low Blood Pressure
Yes
No
Bruise Easily
Yes
No
Lung Disease
Yes
No
Cancer
Yes
No
Mitral Valve Prolapse
Yes
No
Chemotherapy
Yes
No
Pain in Jaw Joints
Yes
No
Chest Pains
Yes
No
Parathyroid Disease
Yes
No
Cold Sores/Fever Blisters
Yes
No
Psychiatric Care
Yes
No
Congenital Heart Disorder
Yes
No
Radiation Treatments
Yes
No
Convulsions
Yes
No
Recent Weight Loss
Yes
No
Cortisone Medicine
Yes
No
Renal Dialysis
Yes
No
Diabetes
Yes
No
Rheumatic Fever
Yes
No
Drug Addiction
Yes
No
Rheumatism
Yes
No
Easily Winded
Yes
No
Scarlet Fever
Yes
No
Emphysema
Yes
No
Shingles
Yes
No
Epilepsy or Seizures
Yes
No
Sickle Cell Disease
Yes
No
Excessive Bleeding
Yes
No
Sinus Trouble
Yes
No
Excessive Thirst
Yes
No
Spina Bifida
Yes
No
Fainting Spells/Dizziness
Yes
No
Stomach/Intestinal Disease
Yes
No
Frequent Cough
Yes
No
Stroke
Yes
No
Frequent Diarrhea
Yes
No
Swelling of Limbs
Yes
No
Frequent Headaches
Yes
No
Thyroid Disease
Yes
No
Genital Herpes
Yes
No
Tonsillitis
Yes
No
Glaucoma
Yes
No
Tuberculosis
Yes
No
Hay Fever
Yes
No
Tumors or Growths
Yes
No
Heart Attack/Failure
Yes
No
Ulcers
Yes
No
Heart Murmur
Yes
No
Venereal Disease
Yes
No
Heart Pace Maker
Yes
No
Yellow Jaundice
Yes
No
Heart Trouble/Disease
Yes
No
Have you ever had any serious illness not listed above ?
Yes
No
If yes, please explain:
Comments:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responisbility to inform the dental office of any changes in medical status.
