Medical History Form

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 NameFirst NameMiddle Name
Preferred Name
Phone Number

Area CodePhone 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

Other
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?
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.
Response Date

MonthDayYear
Date
Should be Empty: