Medical History Form
Patient Information
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
What is your gender?
Please Select
Male
Female
N/A
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Medical Information
Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems 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 currently seeing a Family Physician?
*
Yes
No
Please enter the name, phone number, and date of your last visit:
Have you recently (in the last two years) been hospitalized or had a major operation?
*
Yes
No
Please explain:
Have you ever had a serious head or neck injury?
*
Yes
No
Please explain:
Are you or could you be pregnant?
*
Yes
No
Are you taking oral contraceptives?
*
Yes
No
Do you use any form of tobacco or are you using a nicotine patch?
*
Yes
No
Are you dependent on alcohol or drugs?
*
Yes
No
Medications
Are you currently taking or have recently taken any prescription or non-prescription medication?
*
Yes
No
Please list medication(s) with dosage(s):
Have you ever been advised against taking any type of medication?
*
Yes
No
Please list medication(s) with dosage(s):
Are you currently taking blood thinners?
*
Yes
No
Are you currently taking or have taken bone medication (bisphosphonate)?
*
Yes
No
Allergies
Are you allergic to any of the following?
*
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anaesthetics
No allergies
Other
Please explain:
Please go over the following section and indicate which of the following you have or have had.
*
AIDS/HIV Positive
Alzehimer's Disease
Angina
Asthma
Artificial Heart Valve
Artificial Joint
Blood Transfusion
Chemotherapy
Cancer
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Cortisone Medicine
Diabetes
Drug Addiction
Epilepsy/Seizures
Fainting
Frequent Headaches
Glaucoma
Hemophilia
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Surgery
Hepatitis A
Hepatitis B or C
High or Low Blood Pressure
Hives or Rash
Hypoglycemia
Kidney Problems
Leukemia
Liver Disease
Lung Disease
Mitral Valve Prolapse
Osteoperosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatment
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Stomach Disease
Stroke
Thyroid Disease
Tonsilitis
Tuberculosis
Tumors or Growths
None of the above
Have you ever had any serious illness not listed above?
*
Yes
No
Please explain:
Signature
To the best of my knowledge, the questions on this form have been accurately answered. Iunderstand the 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 medical status.
Signature of Patient, Parent or Legal Guardian
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: