www.titusdentistrymiddletown.com - Patient Medical History Form

Patient Medical History Form - Middletown
Patient Name

First NameMiddle NameLast Name
Gender
General Medical Information
Physician type
Physician's Name
Physician's Phone Number
I have been hospitalized or have required a major operation
Please Explain
I have been involved in a serious head or neck injury
Please Explain
I am currently on a special diet
Please Explain
I am or have taken Phen-Fen or Redux
Please Explain
I use tobacco
Please describe the current amount and frequency as well as the length of use
I use alcohol
Please describe the current amount and frequency as well as the length of use
I use a controlled substance
Please describe the current amount and frequency as well as the length of use
I required an antibiotic prior to dental appointments
Please tell us what antibiotic and dosage you take
Please list any prescription or over the counter medications and herbal supplements you currently take.
Have you had any surgeries?
Please describe
Preferred Pharmacy
Allergies
Please list
For Women
Medical Conditions
Please list any other illnesses you have had that are not listed above
Signature
Name of person completing this form

First NameLast Name
Date

MonthDayYear
Date
Please verify that you are human
Should be Empty:

Patient Medical History Form - Middletown