Form

Medical History

First Name

Last Name

Medical Doctor

Phone

Most Recent Physical Examination

Purpose

What is your estimate of your general health?

Have you or anyone in your household had COVID-19?

When?

Are you or have you had a fever in the last 24 to 48 hours?

Please explain:

Please advise us of any change in your medical history or medications, including over the counter, you are taking.

Have you ever been hospitalized for an illness or injury?

Please List:

Have you ever had an allergic reaction to any medications?

Please List:

Are you presently being treated for any illness?

Please List:

Are you aware of a change in your overall health?

Please Explain:

Please list ALL medications you take:

Have you ever had the following?

Heart Problems

Heart Murmur

Rheumatic Fever

Scarlet Fever

Abnormal Blood Pressure

Stroke

Artificial Prosthesis (Heart Valve or Joints)

Anemia or other Blood Disorder

Prolonged bleeding due to slight cut

Emphysema

Tuberculosis

Asthma

Sinus Problems

Kidney Disease

Diabetes

Glaucoma

Contact Lens

Head or Neck Injuries

Epilepsy, Convulsions, Seizures

Viral Infections & Cold Sores

Hives, Skin Rash, Hay Fever

Hepatitis A

Hepatitis B or C

HIV/ AIDS

Tumor/ Abnormal Growth

Radiation Therapy

Chemotherapy

Thyroid or Parathyroid Disease

Hormone Deficiency

High Cholesterol

Any Lumps or Swelling in the Mouth

Emotional Problems

Psychiatric Problems

Antidepressant Medication

Alcohol / Drug Dependency

Often Exhausted or Fatigued

Subject to Frequent Headaches

Considered a touchy person

Often Unhappy or Depressed

Easily Upset or Irritated

Digestive Disorders

Stomach or Dudenal Ulcer

Liver Disease

Jaundice

Venereal Disease

Do you:

How many years?

Are you taking birth control pills/ medication?

Are you pregnant?

How Far Along?

Prostate Disorders?

Do you take ED medication?

Please describe ANY OTHER medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment

I certify that I have read and I understand the questions asked. I certify I have answered these questions in completion and do not hold the practice, doctor(s), or team responsible for any errors or omission that I have made in completing these forms.

Patient/Legal Guardian Signature

Date