Medical History Form

Prefix:

MrMrsMsDr

DOB:

Age:

Sex:

MaleFemale

How did you find us?: GoogleWebsiteFriend/FamilyStreet Sign

Who can we thank for your referral?

If you don't know please put NA

Are you currently under physician care?
YesNo

Are you currently taking any medication (including supplements and vitamins)?
YesNo

If yes, list medications and reasons for taking and indicate if you take it in the AM or PM:

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

Do you take any blood thinners

NoYes

Has your doctor stated that you need to pre-medicate with antibiotics before dental visits?

NoYes

Artificial / Damaged heart valves?

NoYes

Congenital heart defect?

NoYes

Prosthetic joint?

NoYes

History of heart attack? Angina? Chest pain on exertion? Pacemaker?

NoYes

High blood pressure? Do your ankles swell? Low blood pressure / dizziness?

NoYes

Sinus problems?

NoYes

Asthma? Other lung/breathing problems?

NoYes

Hepatitis, jaundice, other liver dysfunction?

NoYes

HIV?

NoYes

Sexually-transmitted disease?

NoYes

Thyroid problems?

NoYes

Arthritis? Swollen joints?

NoYes

Tuberculosis?

NoYes

Persistent cough that products blood?

NoYes

Stomach ulcers or other gastrointestinal problem?

NoYes

Kidney problems?

NoYes

Epilepsy or seizures?

NoYes

Cancer?

NoYes

Diabetes or high glucose?

NoYes

Psychiatric care?

NoYes

Low immune function?

NoYes

Bleeding disorders?

NoYes

Are you wearing contact lenses?

NoYes

Do you have osteoporosis or osteopenia?

NoYes

Do you smoke or use other forms of tobacco?

NoYes

Our office offers IV Sedation (Twilight Sleep). Would you like to discuss this as an option?

NoYes

Have you had any general surgeries?

NoYes

Do you take or have you ever taken any bisphosphonate (i.e. Fosamax, Actonel, Boniva, etc)

NoYes

When was your last dental cleaning?

How often do you have cleanings?

Have you had any serious problems with dental treatment?

NoYes

Do you have any medical disease or condition that is not listed?

NoYes

If you answered Yes to any of the above questions, please provide a brief history with relevant dates:

Do you have an allergy to or have you had a bad reaction to:

Are there any medications you cannot or prefer not to take?

NoYes

Local anesthetics (i.e. Novocain)

NoYes

General anesthetics/sedation medication

NoYes

Antibiotics

NoYes

Sulfite (red wine)

NoYes

Aspirin

NoYes

Codeine or other narcotics

NoYes

Do you have any medical disease or condition that is not listed?

Women

Are you, or do you think that you might be pregnant?

NoYes

Are you nursing?

NoYes

Do you take birth control pills?

NoYes

Do you have problems with your menstrual period?

NoYes

Men

Do you take Viagra, Cialis or Levitra?

NoYes

Disclaimer

I certify that I have read and understand the above. I acknowledge that my questions regarding this form have been answered to my satisfaction. I will not hold my dentist or any other member of the office staff responsible for errors or omissions that I may have made in the completion of this form. I acknowledge that if I make omissions or false statements, my health may be put at risk.

Signature of Patient or Patient's Representative

Date

Relationship to Patient (If not signed by the Patient)