Medical History

Medical & Dental Health History
Patient: Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Primary Care Physician [PCP]*
Primary Care Physician [PCP] - City*
Primary Care Physician [PCP] - Phone Number*
Are you being treated by a specialist?*

YesNo
Specialist Name*
Specialist - City*
Specialist - Phone Number*
Do you have, or have your recently had, any of the following. [CHECK ALL THAT APPLY]

ADD/ADHDConvulsions/SeizuresHives/RashSickle Cell DiseaseAlzheimers/Parkinsons DiseaseCOPD, Emphysema or AsthmaKidney Problems/DialysisStomach/Intestinal DiseaseAnemiaDiabetes/HypoglycemiaLiver DiseaseStrokeAnxiety or DepressionFatigueMental illnessSwelling of LimbsArthritis / RheumatismGlaucomaNauseaTyroid ConditionBlood ClotHeadachesPTSDUlcersBreathing/Lung ProblemsHearing problems/ImpairmentRadiation/ChemotherapyVision problems/ImpairmentChemical DependencyHigh Blood Pressure (Hypertension)Seizures/TremorsWeaknessChest Pain or DiscomfortHigh CholesterolShinglesWeight loss/gain
Review the following infections diseases and check-off all items that apply to you.

AIDS/HIVChicken PoxHepatitisScarlet FeverMalariaMeaslesLyme DiseaseSTDsMumpsCholeraEncephalitisParasite InfectionPoliomyelitisRheumatic FeverTetanusTuberculosisWhooping CoughOther

Please list all current medications you are taking. If you are taking more than can be listed, please speak with the patient specialist.

Do you take bisphosphonates (ex: Fosamax, Reclast, Zometa, Atonel, or Boniva)?*

YesNo
Dosage (mg) / Times per Day
Do you take blood thinners (ex: Coumadin, Heparin, or Plavix)?*

YesNo
Dosage (mg) / Times per Day
Are you allergic to any medications?*

YesNo
Please specify:
Do you have allergies to anything other than medication?*

YesNo
Please specify:
Have you ever been hospitalized or had a major operation?*

YesNo
Please specify:
Are you pregnant or trying to become pregnant?*

YesNo
Are you taking oral contraceptives?*

YesNo
Are you a current smoker?*

YesNo
Are you a former smoker?*

YesNo
Do you drink alcohol?*

YesNo
Do you use controlled substances?*

YesNo
Do you have a "DO NOT RESUSCITATE ORDER"?*

YesNo
NOTE: We requires that a copy be on file prior to being seen.
Is this your first visit to a dentist?*

YesNo
When was your last visit?
Previous Dentist Name
Signature of Patient/Guardian*

Clear
SUBMISSION DATE

MonthDayYear
Date
Should be Empty: