Medical History Form

Medical History Form
Patient Information
Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
What is your gender?
Contact Number*
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?*

YesNo
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?*

YesNo
Please explain:
Have you ever had a serious head or neck injury?*

YesNo
Please explain:
Are you or could you be pregnant?*

YesNo
Are you taking oral contraceptives?*

YesNo
Do you use any form of tobacco or are you using a nicotine patch?*

YesNo
Are you dependent on alcohol or drugs?*

YesNo
Medications
Are you currently taking or have recently taken any prescription or non-prescription medication?*

YesNo
Please list medication(s) with dosage(s):
Have you ever been advised against taking any type of medication?*

YesNo
Please list medication(s) with dosage(s):
Are you currently taking blood thinners?*

YesNo
Are you currently taking or have taken bone medication (bisphosphonate)?*

YesNo
Allergies
Are you allergic to any of the following?*

AspirinPenicillinCodeineAcrylicMetalLatexLocal AnaestheticsNo allergiesOther
Please explain:
Please go over the following section and indicate which of the following you have or have had.
AIDS/HIV PositiveAlzehimer's DiseaseAnginaAsthmaArtificial Heart ValveArtificial JointBlood TransfusionChemotherapyCancerChest PainsCold Sores/Fever BlistersCongenital Heart DisorderCortisone MedicineDiabetesDrug AddictionEpilepsy/SeizuresFaintingFrequent HeadachesGlaucomaHemophiliaHeart Attack/FailureHeart MurmurHeart Pace MakerHeart SurgeryHepatitis AHepatitis B or CHigh or Low Blood PressureHives or RashHypoglycemiaKidney ProblemsLeukemiaLiver DiseaseLung DiseaseMitral Valve ProlapseOsteoperosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentRenal DialysisRheumatic FeverScarlet FeverSickle Cell DiseaseSinus TroubleStomach DiseaseStrokeThyroid DiseaseTonsilitisTuberculosisTumors or GrowthsNone of the above
Have you ever had any serious illness not listed above?*

YesNo
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*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Medical History Form

Patient Information

Medical Information

Medications

Allergies

Please go over the following section and indicate which of the following you have or have had.

Signature