Medical History

Patient Name

Birth Date

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician`s care now?	YesNo	If yes, please explain:
Have you ever been hospitalized or had a major operation?	YesNo	If yes, please explain:
have you ever had serious, pills, or drugs?	YesNo	If yes, please explain:
Are you talking any medications, pills, or drugs?	YesNo	If yes, please explain:
Do you take, or have you taken, Phen-fen or redux?	YesNo	If yes, please explain:
Are you on a special diet?	YesNo	If yes, please explain:
Do you use tobacco?	YesNo	If yes, please explain:
Do you use controlled substances?	YesNo	If yes, please explain:

Women: Are you

Pregnant / trying to get Pregnant

YesNo

Taking oral contraceptives?

YesNo

Nursing

YesNo

Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalLatexLocal Anesthetics

Other

if yes, please explain:

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

Aids / hiv positive	YesNo
Alzheimer`s Disease	YesNo
Anaphylaxis	YesNo
Anemia	YesNo
Angina	YesNo
AnginaArthritis / Gout	YesNo
Artificial heart valvez	YesNo
Artificial Joint	YesNo
Asthma	YesNo
Blood Disease	YesNo
Blood Transfusion	YesNo
Breathing Problem	YesNo
Bruise Easily	YesNo
Cancer	YesNo
Chemotherapy	YesNo
Chest pains	YesNo
Cold sores/Fever Blisters	YesNo
Congenital heart disorder	YesNo
Convulsions	YesNo
Cortisone medicine	YesNo
Diabetes	YesNo
Drug Addiction	YesNo
Easily Winded	YesNo
Emphysema	YesNo
Epilepsy or Seizures	YesNo

Excessive Bleeding	YesNo
Excessive Thirst	YesNo
Fainting Spells/Dizziness	YesNo
Frequent cough	YesNo
Frequent Diarrhea	YesNo
Frequent Headaches	YesNo
Genital Herpes	YesNo
Glaucoma	YesNo
Hay Fever	YesNo
Heart Attack/Failure	YesNo
Heart Murmur	YesNo
Heart pace maker	YesNo
heart Trouble/Disease	YesNo
Hemophilia	YesNo
hepatitis A	YesNo
Hepatitis B or C	YesNo
Herpes	YesNo
High Blood Pressure	YesNo
hives or rash	YesNo
Hypoglycemia	YesNo
Irregular Heartbeat	YesNo
kidney problems	YesNo
leukemia	YesNo
Liver Disease	YesNo
Low Blood Pressure	YesNo

Lung Disease	YesNo
mitral valve prolapsed	YesNo
pain in jaw joints	YesNo
Parathyroid disease	YesNo
Psychiatric Care	YesNo
Radiation treatments	YesNo
Recent Weight Loss	YesNo
Renal Dialysis	YesNo
Rheumatic fever	YesNo
Rheumatism	YesNo
Scarlet Fever	YesNo
Shingles	YesNo
Sickle Cell Disease	YesNo
Sinus Trouble	YesNo
Spina Bifida	YesNo
Stomach/Intestinal Disease	YesNo
Stoke	YesNo
Swelling of Limbs	YesNo
Thyroid disease	YesNo
Tonsillitis	YesNo
Tuberculosis	YesNo
Tumors or Growths	YesNo
Ulcers	YesNo
Venereal Disease	YesNo
Yellow Jaundice	YesNo

Have you ever had any serious illness not listed above?

YesNo

if yes, Please explain:

Comments:

To the best of my knowledge. The questions on this from have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient`s) health. It is my responsibility to inform the dental office of any changes medical status.

Signature of patient, parent, or Guardian

Date