MEDICAL AND DENTAL HEALTH HISTORY
Please fully complete the applicable fields below so that we can best serve you!
Patient Name
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Birth Date
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Month
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Day
Year
Date
Physician's Name
*
Phone #
Format: (000) 000-0000.
Date of Last Visit
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Month
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Day
Year
Date
Have you had any serious operations?
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Yes
No
Please list any serious operations:
Leave this blank if it does not apply to you.
Are you pregnant?
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Yes
No
If you are pregnant, what is your due date?
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Month
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Day
Year
Date
Are you nursing?
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Yes
No
Are you taking birth control medication?
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Yes
No
Are you allergic to any of the following?
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Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
Other
None of the above
Are you taking any medications, pills, drugs, or controlled substances?
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Yes
No
Please list any medications, pills, drugs, or controlled substances you are taking:
Leave this blank if it does not apply to you.
Do you use tobacco?
*
Yes
No
Are you on a special diet?
*
Yes
No
Do you have any of the following (please check all that apply):
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AIDS/HIV Positive
Diabetes
Hemophilia
Radiation Treatments
Alzheimer's Disease
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Rheumatism
Scarlet Fever
Artificial Joint
Shingles
Sickle Cell Disease
Asthma
Hypoglycemia
Irregular Heartbeat
Leukemia
Blood Disease
Sinus Trouble
Blood Transfusion
Spina Bifida
Breathing Problems
Liver Disease
Bruise Easily
Cancer
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Low Blood Pressure
Stroke
Lung Disease
Swelling of Limbs
Thyroid Disease
Tonsillitis
Chemotherapy
Hay Fever
Cold Sore/Fever Blisters
Heart Murmur
Tuberculosis
Congenital Heart Disorder
Heart Pacemaker
Parathyroid Disease
Ulcers
Heart Trouble/Disease
Venereal Disease
Ulcers
Anxiety/Depression
TMJ
Yellow Jaundice
Stomach/Intestinal Disease
Psychiatric Care
Convulsions
Heart Attack/Failure
Chest Pains
Cortisone Medicine
None of the above
Have you ever had any serious illnesses not listed?
*
Yes, explain below
No
Explain your serious illness not listed above:
Leave this blank if it does not apply to you.
Have you ever had a serious head or neck injury?
*
Yes, explain below
No
Explain your serious head or neck injury:
Leave this blank if it does not apply to you.
Have you ever been hospitalized or had a major operation?
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Yes, explain below
No
Explain your major operation or hospitalization:
Leave this blank if it does not apply to you.
Have you ever had an allergic reaction to Novocain, local or general anesthetics?
*
Yes, explain below
No
Explain your allergic reaction to Novocain, local or general anesthetics:
Leave this blank if it does not apply to you.
Have you had trouble from previous dental care?
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Yes, explain below
No
Explain any trouble from previous dental care:
Leave this blank if it does not apply to you.
Does your primary doctor recommend a pre-medication for dental visits?
*
Yes, explain below
No
Explain your doctor's recommended pre-medication for dental visits:
Leave this blank if it does not apply to you.
AUTHORIZATION AND RELEASE
I have read and answered the above questions to the best of my knowledge.
Patient/Guardian Signature
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Date
*
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Month
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Day
Year
Date
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