Medical History Form

Medical History
Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email
example@example.com
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birthdate

Month Day Year
Date
Reason for visit (please be as specific as possible)
How did you find Dr. Liotta? Who may we thank for referring you?
Check the conditions that apply to you or to any members of your immediate relatives: *

Asthma Cancer Cardiac disease Diabetes Hypertension Epilepsy Heart arrhythmia History of problems with anesthesia none
Are you currently taking any medication? *

Yes No
If yes, please list your medications
Do you have any medication allergies? *

Yes No Allergy to Latex Allergy to local anesthesia
If yes, please list any medications you are allergic to
Do you use or do you have history of using tobacco? *
If you responded yes, please explain
Do you use or do you have history of using illegal drugs? *
If you responded yes, please explain
How often do you consume alcohol? *

Daily Weekly Monthly Occasionally Never
Signature

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