Form

*Medical History Form*

Patient First Name

Patient Last Name

ONE FORM PER PATIENT

Must be completed by new and current patients and updated every 2 YEARS.
If this is an update, think of the last two years when answering the questions.

Is the patient under any medical treatment now?

If Yes

Has the patient ever been hospitalized in last 2 years?

If Yes

Does the patient have any heart problems, defects, or murmurs?

If Yes

Does the patient require antibiotics prior to their dental appointments?

If Yes

Does the patient have a speech, cognitive, or emotional difference that may impact treatment?

If Yes

Allergies

Does the patient have any allergies?

If other, please specify

If Yes

Medical Conditions

Does the patient have any of the conditions listed?

Please specify other condition(s) not listed above

If Yes

Is the patient currently taking any drugs or medications? If yes, please list

If Yes