Simcoe Family Dentistry Medical History Form

MEDICAL HISTORY FORM
Name*
Birth Date*

MonthDayYear
Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health p roblems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician’s care now?*

YESNO
If Yes, please explain
Have you ever been hospitalized or had a major operation?*

YESNO
If Yes, please explain
Have you ever had a serious head or neck injury?*

YESNO
If Yes, please explain
Are you taking any medication, pills, or drugs?*

YESNO
If Yes, please explain
Do you take, or have you taken bone medication?*

YESNO
Do you take, or have you taken, Phen-Fen or Redux?*

YESNO
Are you on a special diet?*

YESNO
Do you use tobacco?*

YESNO
Do you use controlled substances?*

YESNO
Women: Are you...
Pregnant/trying to get pregnant?*

YESNOOther
Nursing?*

YESNO
Taking oral contraceptives?*

YESNO
Are you allergic to any of the following?*

AspirinPenicillin CodeineAcrylicMetalLatexLocal AnaestheticsOtherNone
If Other, please explain
Do you have, or have had any of the following?

AIDS/HIV PositiveChest PainsFrequent HeadachesIrregular HeartbeatRheumatismAlzheimer’s DiseaseCold Sores/Fever BlistersGenital HerpesKidney ProblemsScarlet FeverAnaphylaxisCongenital Heart DisorderGlaucomaLeukemiaShinglesAnemiaConvulsionsHemophiliaLiver DiseaseSickle Cell DiseaseAnginaCortisone MedicineHay FeverLow Blood PressureSinus TroubleArthritis/GoutDiabetesHeart Attack/FailureLung DiseaseSpina BifidaArtificial Heart ValveDrug AddictionHeart MurmurMitral Valve ProlapseStomach DiseaseArtificial JointEasily WindedHeart Pace MakerOsteoporosisStrokeAsthmaEmphysemaHeart Trouble/DiseasePain in Jaw JointsSwelling of LimbsBlood DiseaseEpilepsy or SeizuresHepatitis AParathyroid DiseaseThyroid DiseaseBlood TransfusionExcessive BleedingHepatitis B or CPsychiatric CareTonsillitisBreathing ProblemExcessive ThirstHerpesRadiation TreatmentsTuberculosisBruise EasilyFainting Spells/DizzinessHigh Blood PressureRecent Weight LossTumors & GrowthsCancerFrequent CoughHives or RashRenal DialysisUlcersChemotherapyFrequent DiarrheaHypoglycemiaRheumatic FeverVenereal DiseaseYellow Jaundice
Have you ever had any serious illness not listed above?*

YESNO
If Yes, please explain
Comments
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in the medical status.
Signature of patient, parent or guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL HISTORY FORM