Medical History Form

Patient Name

Birth date

Today's 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 dentistry you will receive. Thank you for answering the following questions.

Have you ever been hospitalized or had a major operation within the last year?

Yes

If yes, please specify

Are you taking any medications, pills, or drugs?

Yes

If yes, please specify

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

Yes

If yes, please specify

Do you use tobacco?

Yes

Women: Are you...

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives

Are you allergic to any of the following?

Penicillin

Latex

Codeine

Sulfa Drugs

Acrylic

Local Anesthetics

Metal

Any other allergies?

Yes

If yes, please specify

Do you use controlled substances?

Yes

If yes, please specify

AIDS/HIV Positive

Yes

Breathing Problems

Yes

Diabetes

Yes

Excessive Bleeding

Yes

Heart Murmur

Yes

Hepatitis A

Yes

Irregular Heartbeat

Yes

Lung Disease

Yes

Sickle Cell Disease

Yes

Thyroid Disease

Yes

Artificial Heart Valve

Yes

Cancer

Yes

Drug Addiction

Yes

Fainting Spells/Dizziness

Yes

Heart Pacemaker

Yes

Hepatitis B or C

Yes

Kidney Problems

Yes

Recent Weightloss

Yes

Sinus Trouble

Yes

Tuberculosis

Yes

Artificial Joint

Yes

Chemo/Radiation therapy

Yes

Emphysema

Yes

Glaucoma

Yes

Heart Disease

Yes

High Blood Pressure

Yes

Leukemia

Yes

Renal Dialysis

Yes

Stomach/Intestinal Disease

Yes

Ulcers

Yes

Blood Disease

Yes

Congenital Heart Disorder

Yes

Epilepsy or Seizure

Yes

Hay Fever

Yes

Hemophilia

Yes

Hypoglycemia

Yes

Liver Disease

Yes

Rheumatic Fever

Yes

Stroke

Yes

Have you ever had any serious illness not listed above?

Yes

If yes, please specify

Updates

Change of address:

Yes

If yes, please provide your new address

Email address:

Yes

If yes, please specify

Cell #:

Yes

If yes, please specify

Would you like text appointment reminders?

Yes

HIPAA/Materials Data

I have received a copy of the Dental Materials Fact Sheet as required by law.

Yes

I have received a copy of the Notice of Privacy Practices.

Yes

Comments

To the best of my knowledge, the questions on this form 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 in medical status.

Signature of Patient, Parent of Guardian

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue