Medical History Form

OR FILL OUT THIS FORM ONLINE

 

Patient Name:
Birth Date:

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

YesNo
If yes, please explain:

Have you ever been hospitalized or had a major operation?

YesNo
If yes, please explain:

Have you ever had a serious head or neck injury?

YesNo
If yes, please explain:

Are you taking any medications, pills, or drugs?

YesNo
If yes, please explain:

Do you take, or have you taken, Phen-Fen or Redux?

YesNo

Are you on a special diet?

YesNo

Do you use tobacco?

YesNo

Do you use controlled substances?

YesNo

Do you need to pre-medicate?

YesNo
If yes, please explain:
Women:

Are you Pregnant/Trying to get pregnant?

YesNo

Taking oral contraceptives?

YesNo

Nursing?

YesNo

Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalLatexLocal Anesthetics
If yes, please explain:
Do you have, or have you had, any of the following?
AIDS/HIV Positive
YesNo
Cortisone Medicine
YesNo
Hemophilia
YesNo
Renal Dialysis
YesNo
Alzheimer's Disease
YesNo
Diabetes
YesNo
Hepatitis A
YesNo
Rheumatic Fever
YesNo
Anaphylaxis
YesNo
Drug Addiction
YesNo
Hepatitis B or C
YesNo
Rheumatism
YesNo
Anemia
YesNo
Easily Winded
YesNo
Herpes
YesNo
Scarlet Fever
YesNo
Angina
YesNo
Emphysema
YesNo
High Blood Pressure
YesNo
Shingles
YesNo
Arthritis/Gout
YesNo
Epilepsy or Seizures
YesNo
Hives or Rash
YesNo
Sickle Cell Disease
YesNo
Artificial Heart Valve
YesNo
Excessive Bleeding
YesNo
Hypoglycemia
YesNo
Sinus Trouble
YesNo
Artificial Joint
YesNo
Excessive Thirst
YesNo
Irregular Heartbeat
YesNo
Spina Bifida
YesNo
Asthma
YesNo
Fainting Spells/Dizziness
YesNo
Kidney Problems
YesNo
Stomach/Intestinal Disease
YesNo
Blood Disease
YesNo
Frequent Cough
YesNo
Leukemia
YesNo
Stroke
YesNo
Blood Transfusion
YesNo
Frequent Diarrhea
YesNo
Liver Disease
YesNo
Swelling of Limbs
YesNo
Breathing Problem
YesNo
Frequent Headaches
YesNo
Low Blood Pressure
YesNo
Thyroid Disease
YesNo
Bruise Easily
YesNo
Genital Herpes
YesNo
Lung Disease
YesNo
Tonsillitis
YesNo
Cancer
YesNo
Glaucoma
YesNo
Mitral Valve Prolapse
YesNo
Tuberculosis
YesNo
Chemotherapy
YesNo
Hay Fever
YesNo
Pain in Jaw Joints
YesNo
Tumors or Growths
YesNo
Chest Pains
YesNo
Heart Attack/Failure
YesNo
Parathyroid Disease
YesNo
Ulcers
YesNo
Cold Sores/Fever Blisters
YesNo
Heart Murmur
YesNo
Psychiatric Care
YesNo
Venereal Disease
YesNo
Congenital Heart Disorder
YesNo
Heart Pace Maker
YesNo
Radiation Treatments
YesNo
Yellow Jaundice
YesNo
Convulsions
YesNo
Heart Trouble/Disease
YesNo
Recent Weight Loss
YesNo

Have you ever had any serious illness not listed above?

YesNo
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 responsibility to inform the dental office of any changes in medical status.

 

SIGNATURE OF PATIENT, PARENT, or GUARDIAN

DATE