PROFESSIONAL LANE DENTAL
102 Professional Lane
Dothan, Alabama 36303
Health History Form
Patient Name
*
First Name
Last Name
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Medical History, each box must be answered yes or no
*
Rows
Yes
No
Acid Reflux
Alcohol/Chemical Dependency
Alzheimers
Anemia
Arthritis
Artificial Joints (Premedication Needed)
Asthma
Autism
Blood Disease
Blood Pressure
High Pressure
Low Pressure
Blood Thinner/Aspirin
Cancer
Chemotherapy
C-Pap Machine
Diabetes
Dizziness
Eating Disorder
Epilepsy/Seizures
Excessive Bleeding
Fainting
Glaucoma
Hay Fever
Head Injuries
Heart Disease (Premedication Needed)
Hepatitis
HIV/AIDS
Kidney Disease
Latex Allergy
Liver Disease
Lupus
Mental Disorders
Mitral Valve Prolapse (Premedication Needed)
Nervous Disorders
Pacemaker
Pregnant Now?
Radiation Treatment
Respiratory Problems
Sinus Problems
Snoring
Stomach Problems
Stroke
Thyroid
Tobacco
Tuberculosis
Tumors
Ulcers
Veneral Disease
Any other medical condition we need to know about?
Have you ever had an allergic reaction to dental injection/novocaine?
Allergies to any of the below items?
Latex
Codeine
Penicillin
Sulfa
Eggs
Current Medication & Dosage
Patient Signature
*
Submit
Print Form
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