Patient Medical History  Form
 

 
1. Patient Information
First Name:       MI: 
Last Name: 
Do you have a personal physician?    Yes      No
Physician's Name: 
Phone Number:   - -    
Date of Last Visit: 
Are you currently under the care of a physician?

  Yes      No
Please explain:
Are you taking any prescription / over-the-counter drugs?
  Yes      No
Please list each one: 
For Women:  Are you taking birth control?  

  Yes      No
Are you pregnant?

   Yes      No          Week # 

Are you nursing?    Yes      No  
 

Have you ever had any of the following
disease or medical problems?
Yes    No      Abnormal Bleeding
Yes    No      Anemia / Radiation Treatment
Yes    No      Artificial Bones / Joints / Valves
Yes    No      Asthma / Arthritis
Yes    No      Blood Transfusion
Yes    No      Cancer / Chemotherapy
Yes    No      Congenital Heart Defect
Yes    No      Diabetes / Tuberculosis (TB)
Yes    No      Difficulty Breathing
Yes    No      Drug / Alcohol Abuse
Yes    No      Emphysema / Glaucoma
Yes    No      Epilepsy / Seizures / Fainting
Yes    No      Fever Blisters / Herpes
Yes    No      Heart Attacks / Stroke
Yes    No      Heart Murmur
Yes    No      Heart Surgery / Pacemaker
Yes    No      Hemophilia
Yes    No      Hepatitis
Yes    No      High / Low Blood Pressure
Yes    No      HIV+ / AIDS
Yes    No      Hospitalized for Any Reason
Yes    No      Kidney Problems
Yes    No      Mitral Valve Prolapse
Yes    No      Psychiatric Problems
Yes    No      Rheumatic / Scarlet Fever
Yes    No      Severe / Frequent Headaches
Yes    No      Shingles
Yes    No      Sinus Problems
Yes    No      Ulcers / Colitis
Yes    No      Venereal Disease
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
Yes    No      Aspirin
Yes    No      Any Metals / Plastics
Yes    No      Codeine
Yes    No      Dental Anesthetics
Yes    No      Erythromycin
Yes    No      Latex
Yes    No      Penicillin
Yes    No      Tetracycline
Yes    No      Other
Please list any other drugs / materials that you are allergic to:
 
What are the main concerns that you would like dentist to accomplish?
Have you ever had a serious / difficult problem associated with any previous dental work?

Yes    No
Do you take appetite suppressants?

Yes    No
Your current dental health is:  

  Good      Fair   Poor 

Are you apprehensive about dental treatment?

Yes    No