Medical History

Patient Name

First NameLast Name

Have you been under the care of a medical doctor during the past two years?

YesNo

If yes, for what reason(s)?

Physician's Name

Physician's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you taken any medication or drugs during the past two years?

YesNo

Are you taking any medications, drugs or pills now?

YesNo

If yes, please list the Medication, the dose, and the reason for taking:

Are you aware of having an allergic (or adverse) reaction to any medication or substance?

YesNo

If yes, please list the Medication or Substance:

Have you been a patient in the hospital during the past five years?

YesNo

Indicate which of the following you have had, or have at present:*

Rows	Yes	No
Heart (Disease, Surgery, Attack)
Chest Pain
Congenital Heart Disease
Heart Murmur
High Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve
Heart Pacemaker
Rheumatic Fever
Arthritis/Rheumatism
Cortisone Medicine
Swollen Ankles
Stroke
Diet (Special/Restricted)
Artificial Joints (Hip, Knee, etc.)
Kidney Trouble
Ulcers
Diabetes
Thyroid Problems
Glaucoma
Contact Lenses
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever
Latex Sensitivity
Allergies or Hives
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis A (Infectious) B (Serum)
Venereal Disease
A.I.D.S.
H.I.V. Positive
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Sickle Cell Disease
Bruise Easily
Liver Disease
Yellow Jaundice
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
Psychiatric/Psychological Care

Have you lost or gained more than 10 pounds in the past year?

YesNo

Do you have or have you had any disease, condition, or problem not listed?

YesNo

If yes, please list:

(Women) Are you pregnant?

YesNo

If yes, how far along are you?

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

Signature of Patient or Parent/Legal Guardian

Date