cosmeticsmile.net - Health History Form

Medical History Update
Patient Name
Date of birth

MonthDayYear
Date
Physician's Name
Phone Number
Please enter a valid phone number.
Have you had any medical care within the past two years?

YesNo
If yes, please describe.
Are you aware of having an allergic (or adverse) reaction to any substance or medication?

YesNo
If yes, please describe.
Have you been a patient in the hospital during the past five years?

YesNo
Have you ever had an artificial joint replacement (e.g., hip, knee, shoulder)?

YesNo
If yes, please specify
Indicate which of the following you have had or currently have by checking the appropriate box.
Heart & Circulatory Conditions

Heart (Surgery, Disease, Attack)Chest PainCongenital Heart DiseaseHeart MurmurHigh Blood PressureMitral Valve ProlapseArtificial Heart ValvePacemakerStrokeHigh Cholestero
Neurological & Mental Health Conditions

Epilepsy or SeizuresFainting or Dizzy SpellsNervous/AnxiousPsychiatric/Psychological Care
Liver & Kidney Conditions

Kidney TroubleLiver Disease/JaundiceHepatitis A B C (circle)
Blood & Immune Disorders

HemophiliaSickle Cell DiseaseBruise EasilyA.I.D.S./H.I.V. Positive
Metabolic & Endocrine Conditions

OsteoporosisDiabetesThyroid Problems
Respiratory Conditions

AsthmaEmphysemaTuberculosis
Cancer & Treatment

TumorsRadiation TherapyChemotherapy
Gastrointestinal Conditions

Ulcers
Allergies & Sensitivities

Hay Fever/Allergy/HivesLatex Sensitivity
Allergies & Sensitivities

ArthritisCortisone MedicineCold Sores/Fever Blisters
Eye Conditions

Glaucoma
Do you Smoke?

YesNo
Have you lost or gained more than 10 pounds in the past year?

YesNo
If yes, was it intentional?
Do you currently have or have you ever had any medical conditions, diseases, or health concerns not listed above?

YesNo
If yes, please describe.
Women
Are you pregnant or think you could be pregnant?

YesNo
If yes, how many months?
Nursing?

YesNo
Do you currently use prescription birth control?

YesNo
I acknowledge that the information provided is essential for delivering safe and effective dental care. I have answered all questions to the best of my knowledge. If additional information is required, I authorize the provider to contact the appropriate healthcare professional or agency to obtain relevant details. I agree to inform the doctor of any changes in my health or medications.
Patient/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Medical History Update

Indicate which of the following you have had or currently have by checking the appropriate box.

Women