Medical and Dental History

Name

First NameLast Name

Physician's Name

Date of last visit

Date

Are you in general good health ?

If No, explain

Have you had any serious illnesses or surgeries?

If yes, explain

(Women) Are you Pregnant ?

Are You Nursing ?

Taking Birth Control Pills ?

Do You have Allergies ?

Anemia ?

Arthritis, Rheumatism ?

Artificial Heart Valves?

Artificial Joint ?

Asthma ?

Back Problem ?

Bleeding Problem ?

Blood Disease ?

Cancer ?

Chemotherapy ?

If Yes, Describe:

Circulatory Problem ?

Congenital Heart Disease ?

Chest Pain ?

Chemical Dependency ?

Cough, Persistent ?

Cough Up Blood ?

Diabetes ?

Epilepsy or Seizures ?

Fainting Spells ?

Glaucoma ?

Herpes ?

Heart Murmur ?

Heart Problem ?

If Select Yes Explain:

Bleeding Problem ? Replicate

Hemophilia?

Osteoporosis ?

Stomach Problems /Ulcer?

Hepatitis ?

Type:

High Blood Pressure ?

HIV/AIDS ?

Excessive Bleeding ?

Kidney Disease ?

Liver Disease ?

Mitral Valve Prolapse ?

Nervous Problem ?

Pacemaker ?

Psychiatric Care

Radiation Treatment ?

Persistent Cough ? Replicate

Respiratory Disease ?

Seizures ?

Skin Disease ?

Rheumatic Fever ?

Scarlet Fever ?

Short of Breath ?

Skin Rash ?

Stroke ?

Swollen Ankles ?

Thyroid Disease ?

Tobacco Habit ?

Tonsilitis ?

Tuberculosis ?

Ulcer ?

Severe Weight ?

STD

Sinus Problem

Other

Do you have or have you had any other diseases or medical problems NOT listed Above ?

If Yes Explain :

Your Dental History Information: Select all that applies to you.

Have You Ever Been Pre-medicated for Dental Treatment ?

If Selected Yes Explain:

List Medications you are currently taking:

List if you have other medications ?

Pharmacy

Select Medications you are allergic to :

Please List the Metals:

(To be filled in at future appointments)

Date

Health Changes

Patient's Initials

Dentist Initials

Date

Health Changes

Patient's Initials

Dentist Initials

Date

Health Changes

Patient's Initials

Dentist Initials

Date

Health Changes

Patient's Initials

Dentist Initials

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any member of his staff, responsible for any errors or omissions that I may have made in the completion of this form.

Signature of Patient

Date

Medical History

Medical History Information

Dental History

Medications

Allergies

MEDICAL HISTORY UPDATE

SIGNATURE