Form

Patient Medical History(Copy)

Patient First Name

Patient Last Name

Welcome

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us - we will be happy to help.

Are you under medical treatment now?

Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? If yes, please explain.

If Yes

Are you taking any medication(s) including non-perscription medicine? If yes, please list all medications, including vitamins.

If Yes

Have you ever taken Fosamax, Boniva, Actonel, or any cancer medications containing bisphosphonates?

Do you have a persistent cough not associated with a known illness (lasting more than 3 weeks)?

Do you use tobacco?

Do you use controlled substances?

Are you allergic to or have any reactions to the following?

Local Anesthetics (e.g. Lidocaine/Epinep

Penicillin or any other Antibiotics

Sulfa Drugs

Barbiturates

Sedatives

Iodine

Asprin

Any Metals (e.g. nickel, mercury, etc.)

Latex Rubber

Animals, specifically dogs

Do you have any other allergies or reactions to anything not listed above?

If Yes

Have you had a joint replacement? If yes, when and which MD/hospital?

If Yes

Have you had an artificial heart valve? If yes, when and which MD/hospital?

If Yes

Are you on any blood thinners? If yes, please list which one(s).

If Yes

Women only:

Are you pregnant?

Do you think you may be pregnant?

Are you nursing?

Are you taking oral contaceptives?

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

High Blood Pressure

Low Blood Pressure

Heart Attack

Stroke

Heart Murmur

Mitral Valve Prolapse

Cardiac Pacemaker

Heart Disease

Swollen Ankles

Congenital Heart Disease

Hepatitis / Jaundice

Liver Disease

Anemia

Angina

Chest Pains

Asthma

Respiratory Problems

Emphysema

Tuberculosis

Acid Reflux

Stomach Troubles / Ulcers

Hay Fever / Allergies

Frequently Tired

Recent Weight Loss

Arthritis

Osteoporosis

Diabetes Type 1

Diabetes Type 2

Autoimmune Diseases

Fainting / Dizziness

Epilepsy / Seizures

Glaucoma

Kidney Diseases

Cancer

Leukemia

Radiation Therapy

Thyroid Problem

Depression

Anxiety

Eating Disorders

AIDS or HIV Infection

Sexually Transmitted Disease

Signature

Patient, Parent or Guardian