Medical History

Medical History
Date*

MonthDayYear
Name:*

First NameLast Name
Date of Birth:

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Email:*
example@example.com
Preferred Pharmacy & Location:*
Employer:*
Dental Insurance Carrier*
Dental Insurance Subscriber ID / Social Security Number*
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have and important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?*

NoYes
If yes, please explain:
Please list any Allergies:*
Have you ever been hospitalized or had a major operation?*

NoYes
If yes, please explain:
Have you ever had a serious head or neck injury?*

NoYes
If yes, please explain:
Are you on a special diet?*

NoYes
If yes, please explain:
Do you use tobacco?*

NoYes
If yes, please explain:
Do you use controlled substances?*

NoYes
If yes, please explain:
Have you had joint replacement surgery?*

NoYes
If yes, please explain:
Do you need to pre-medicate prior to your dental appointment for any of the following heart conditions?

History of Infective EndocarditisProsthetic Cardiac ValveCardiac Transplant
If yes, please explain:
Are you taking any blood thinners (Coumadin, Warfarin, Eliquis, Pradaxa, Aspirin?*

NoYes
If yes, please explain:
Are you taking currently or have you ever taken bone density meds (Fosamax, Boniva, Zometa, Prolia, Reclast, Bisphosphonates)?*

NoYes
If yes, please explain:
Women only: Are you pregnant or trying to get pregnant?

NoYes

Do you have, or have you had, any of the following?*

Rows	Yes	No
Angina (Chest Pain)
Heart Attack
Congestive Heart Failure
Heart Disease
Congenital Heart Defects
Heart Valves / Implants / Grafts / Stents
Pacemaker / ICD
Mitral Valve Prolapse
Other Heart Surgery
Irregular Heartbeat / Murmur
Palpitations
Stroke
High Blood Pressure
Low Blood Pressure
High Cholesterol
Rheumatic Fever
Fainting Spells
Breathing Problems
Shortness of Breath / Easily Winded
Lung Disease / COPD / Emphysema
Asthma
Sinus Trouble
Sleep Apnea
Diabetes
Hypoglycemia
Kidney Disease
Dialysis
Stomach / Intestinal Disease / Ulcers
Gastric Reflux / GERD
Liver Disease / Cirrhosis / Hepatitis A, B or C
Anemia
Bleeding or Clotting Disorder
Thyroid Disease
Dementia / Alzheimer's
Seizures or Epilepsy
Glaucoma
Mental Health Concerns
Cancer
Radiation / Chemotherapy
Sexually Transmitted Disease
HIV / AIDS
Cold Sores / Fever Blisters
Swelling of Limbs
Frequent Headaches
Pain in Jaw Joints
Scarlet Fever
Sickle Cell Disease

Have you ever had any serious illness not listed?*

NoYes
If yes, please explain:
Please list your medications: (You can also bring a list and we can make a copy)*
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 medical status.
Signature*
*

MonthDayYear
Date
Should be Empty:

Medical History

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 medical status.