Patient Medical History
Patient Name:
*
First Name
Last Name
Today's Date:
*
-
Month
-
Day
Year
Date of Last Visit:
-
Month
-
Day
Year
Date of Medical History:
*
-
Month
-
Day
Year
Physician's name:
*
First Name
Last Name
Physician's Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Name:
Pharmacy Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Sex:
*
Female
Male
If female, please answer the following:
*
Rows
Yes
No
Are you taking Birth Control Pills?
Are you pregnant?
Are you nursing?
If pregnant, how many weeks:
Do you smoke or use tobacco?
*
Yes
No
Do you have any of the following conditions?
*
Rows
Yes
No
Anemia
Angina Pectoris
Artificial Prosthesis
Arthritis
Asthma
Blood Disease
Blood Transfusion
Bruise Easily
Cancer-Chemotherapy
Cerebral Palsy
Cold Sores
Cortisone Medication
Diabetes
Difficulty Swallowing
Drug Abuse
Emphysema
Epilepsy
Excessive Bleeding
Fainting Spells
Glaucoma
HIV+ AIDS
Head Injuries
Heart Attack
Heart Lesions
Heart Murmur
Hemophilia
Hepatitis
Herpes
High Blood Pressure
Joint Replacement
Kidney Problems
Liver Disease
Mental Disorder
Mitral Valve Prolapse
Nervous Disorder
Pace Maker
Psychiatric Problems
Radiation Therapy
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Sickle Cell Disease
Sinus Problems
Stroke
Taken Fen Phen
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Taken Bisphosphonate
Do you have any of the following allergies?
*
Rows
Yes
No
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
Do you have any allergies not listed above? Please list all below:
List all medications you are currently taking below:
Are you using any recreational drugs (marijuana, cocaine, etc.)?
*
Yes
No
If yes, please list below:
Is there any disease, condition, or problem that you think this office should know about that is not covered above?
*
Yes
No
If yes, please list below:
Have you had any surgeries or hospitalizations within the last 5 years?
*
Yes
No
If yes, please list below:
Do you need to pre-medicate prior to dental treatment? (This is usually recommended after any major joint replacement or heart surgery. Please check with your primary care physician if you're uncertain).
*
Yes
No
In case of emergency, who should we call?
First Name
Last Name
Emergency contact phone number:
Please enter a valid phone number.
Format: (000) 000-0000.
Signature (Please use your mouse to sign in box below):
*
Date:
*
-
Month
-
Day
Year
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