Medical History

Medical History
Choose Title
Name

First NameMiddle NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
The thoroughness of the medical history is designed for your safety, and your complete answers will assist us in treating you with consideration of your special needs.
Family Physician
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Last Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Phone Number

Area CodePhone Number
Additional Physician
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Last Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Phone Number

Area CodePhone Number
Other Health Care Professional
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Last Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Phone Number

Area CodePhone Number
Please check YES, NO or UNSURE:
Do you have a current medical problem?
If yes please briefly describe:
Are you currently under the care of a physician for a problem?
Have you ever been hospitalized or had a serious illness within the past 5 years?
Do you have heart trouble or any form of cardiovascular disease?

Other
Do you have diabetes? If YES, how is it controlled?
Do you have hypoglycemia? If YES, how is it controlled?
Do you have kidney disease?
Have you ever had Hepatitis?

Other
Have you ever had liver disease or jaundice?
Do you have any blood disease?

Other
Do you have any problem with excessive bleeding? If YES, please explain
Do you have stomach or intestinal problems?
How many bowel movements do you have per day?
Have you ever had tuberculosis?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Do you have emphysema, asthma, or breathing problems?
Do you have any form of arthritis?

Other
Have you had a hip or other joint replacement or metal inserts or screws?
Have You had your gallbladder removed?
Have you had any other surgeries in your life?
Have you ever had any injury, pain or soreness from your jaw joint? (TMJ dysfunction)
Have you ever suffered trauma to your head or neck, such as in a car accident?If YES, please describe
Do you have fainting spells, convulsions or epilepsy?
Have you had surgery, radiation or other treatment for a tumor or growth?
Do you have glaucoma?
Have you ever been diagnosed with Scoliosis?
Do you have any skin problems? If YES, please explain
Is your diet medically prescribed? If YES, please explain
Are you pregnant?
Expected Delivery Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Do you have a history of miscarriages?
Have you reached menopause? If YES, what hormones are you taking, if any?
Do you take or have you ever taken Bisphosphonates for bone density?
Are you allergic to or have you had any unusual reaction to any of the followingmedications?
Have you ever been advised not to take a particular medication? If YES, please list
Have you ever been advised to take prophylactic antibiotics before dental treatment?
Please list all medications you are currently taking:
Do you or have you ever taken drugs for anxiety or depression?
Do you drink alcohol? If YES, how frequently?
Do you use tobacco? In what form? How many years?
Have you ever had or do you presently have drug problem?(including alcohol or marijuana)
Describe any other medical condition not found in this history
To the best of my knowledge, all the preceding answers are true and correct. If I have any change in my health or medications, I will inform the doctor at my next appointment. If deemed advisable, I grant permission for my physician to be contacted for details and advice. I further authorize the taking of radiographs, photographs, or other diagnostic measures appropriate for a thorough evaluation. Authorization is also given for dental treatment to be rendered by the dentist and office staff, and I will assume financial responsibility.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: