Medical History
Tao Dental Care - www.dentaltao.com, 10011 N. Foothill Blvd #109, Cupertino, CA 95014, yuan.tao.dmd@gmail.com, (408) 737-2988
Patient Name
Last Name
First Name
Middle Name
Preferred Name
Phone Number
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Area Code
Phone Number
Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO"response
*Pre-Med - Amox
Allergy - Aspirin
Allergy - Latex
Anemia
Blood Disease
Dizziness
Glaucoma
Hepatitis
Kidney Disease
Osteoporosis Meds
Radiation Treatment
Sinus Problems
Thyroid Disease
*Pre-Med - Clind
Allergy - Codeine
Allergy - Other
Arthritis
Blood Thinner
Epilepsy
Head Injuries
High Blood Pressure
Liver Disease
Respiratory Problems
STD
Tuberculosis
*Pre-Med - Other
Allergy - Erythro
Allergy - Penicillin
Artificial Joints
Cancer
Excessive Bleeding
Heart Disease
HIV
Mental Disorders
Pacemaker
Rheumatic Fever
Stomach Problems
Tumors
Allergies
Allergy - Hay Fever
Allergy - Sulfa
Asthma
Diabetes
Fainting
Heart Murmur
Jaundice
Nervous Disorders
Pregnancy
Rheumatism
Stroke
Ulcers
Other
Ever been hospitalized (illness or injury)
Presently being treated for any other illnesses
Subject to frequent headaches
(illness or injury) Presently being treated for any other illnesses Subject to frequent headachesT
FEMALE: Taking birth control pills
FEMALE: Pregnant
If any conditions or alerts selected above need further clarification, please describe below:
Do you take antibiotic premedication for your dental visits? If yes, please explain.
What is your estimate of your general health?
Excellent
Good
Fair
Poor
Name of your physician and phone number:
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment
List all medications (prescription and non-prescription) including regular doses of aspirin:
By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly.There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practiceof any future changes. This will serve as my electronic signature.
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Check this box
Response Date
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Month
-
Day
Year
Date
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