www.wahlendental.com - Medical History Form

Medical History
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Physician’s Name
Physician’s Phone Number
Please enter a valid phone number.
Please answer all of the questions with a yes or no and provide answers where applicable
Do you consider yourself to be in good health?*

YesNo
Are you now or have you been under a physician’s care within the past year?*

YesNo
If yes, specify condition being treated*
Do you take any medications, including birth control pills?*

YesNo
Please specify name and purpose of medications*
Do you have or have you ever had any heart or blood problems?*

YesNo
Have you ever been told you have a heart murmur?*

YesNo
Do you require antibiotic premedication for a heart condition, artificial valve or artificial joint?*

YesNo
If yes, specify*
Do you have or have you ever had high blood pressure?*

YesNo
Do you bleed or bruise easily?*

YesNo
Have you ever been diagnosed as being HIV positive or having AIDS?*

YesNo
Have you ever had hepatitis or liver disease?*

YesNo
Have you ever had
Rheumatic Fever*

YesNo
Asthma*

YesNo
Diabetes*

YesNo
Rheumatism*

YesNo
Arthritis/Joint Pain*

YesNo
Heart Disorder*

YesNo
Endocarditis*

YesNo
Heart Attack*

YesNo
Any Blood Disorder*

YesNo
Tuberculosis*

YesNo
Venereal Disease*

YesNo
Kidney Disease*

YesNo
Immune System Disorders*

YesNo
Pneumonia*

YesNo
Other Disease*

YesNo
If "Other Disease" Please Explain*
Have you ever had an unusual reaction or are you allergic to any of the following
Penicillin*

YesNo
Aspirin*

YesNo
Codeine*

YesNo
Ibuprofen*

YesNo
Acetominophen*

YesNo
Barbiturates*

YesNo
Sulfa Drugs*

YesNo
Other*

YesNo
If "Other" Please Explain*
Are you subject to fainting?*

YesNo
Have you ever had any severe reaction to dental treatment or local anesthetics?*

YesNo
Are you allergic to any local anesthetic?*

YesNo
Do you have any other allergies?*

YesNo
If Yes, Please Describe*
Have you ever used or are you now using tobacco or alcohol?*

YesNo
Have you ever received counseling for use of alcohol and/or prescription drugs?*

YesNo
Is there any family history of substance abuse or misuse?*

YesNo
Is there any personal history of substance abuse or misuse?*

YesNo
Do you take any sedative medication including herbal supplements?*

YesNo
Have you ever had a nervous breakdown or undergone psychiatric treatment?*

YesNo
Women only
Are you pregnant?

YesNo
Are you now in pain?*

YesNo
How long ago did you last see a dentist?*
Who was your previous dentist?*
Do you think your teeth are affecting your general health in any way?*

YesNo
Do you have or have you ever had bleeding or sensitive gums?*

YesNo
Have you ever taken Phen-Fen or similar appetite suppressants?*

YesNo
If yes, have you seen your physician or cardiologist for a cardiac evaluation?*
Have you ever taken Fosamax, Boniva or any other drugs prescribed to decrease the resorption of bone as in osteoporosis or any drugs for metastatic bone cancer?*

YesNo
I HEREBY CERFITY THE ANSWERS TO THE FOREGOING QUESTIONS ARE ACCURATE TO THE BEST OF MY ABILITY, SINCE A CHANGE IN MY MEDICAL CONDITION OR IN MEDICATIONS I TAKE CAN AFFECT DENTAL TREATMENT, I UNDERSTAND THE IMPORTANCE OF AND AGREE TO TAKE THE RESPONSIBILITY TO NOTIFY THE DENTIST OF ANY CHANGES AT ANY SUBSEQUENT APPOINTMENT.
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Name*

First NameLast Name
Date*

MonthDayYear
Date
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Medical History

Please answer all of the questions with a yes or no and provide answers where applicable

Have you ever had

Have you ever had an unusual reaction or are you allergic to any of the following

Women only