Medical History

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    Patient Name *

    Date Of Birth *

    PATIENT INFORMATION

    R (leave Blank if you do not understand question)
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    Is your general health good? *

    YesNo

    Has there been a change in your health within the last year? *

    YesNo

    Have you been hospitalized or had a serious illness in the last three years? *

    YesNo

    If YES, why? *

    Are you being treated by a physician now? *

    YesNo

    For what? *

    Date of last medical exam? *

    Date of last Dental exam *

    Have you had problems with prior dental treatment? *

    YesNo

    Are you in pain now? *

    YesNo

    HAVE YOU EXPERIENCED

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    Chest pain (angina)? *

    YesNo

    Swollen ankles? *

    YesNo

    Shortness of breath? *

    YesNo

    Recent weight loss, fever, night sweats? *

    YesNo

    Persistent cough, coughing up blood? *

    YesNo

    Bleeding problems, bruising easily? *

    YesNo

    Sinus problems? *

    YesNo

    Difficulty swallowing? *

    YesNo

    Diarrhea, constipation, blood in stools? *

    YesNo

    Frequent vomiting, nausea? *

    YesNo

    Difficulty urinating, blood in urine? *

    YesNo

    Dizziness? *

    YesNo

    Ringing in ears? *

    YesNo

    Headaches? *

    YesNo

    Fainting spells? *

    YesNo

    Blurred vision? *

    YesNo

    Seizures? *

    YesNo

    Excessive thirst? *

    YesNo

    Frequent urination? *

    YesNo

    Dry mouth? *

    YesNo

    Jaundice? *

    YesNo

    Joint pain, stiffness? *

    YesNo

     

    DO YOU HAVE OR HAVE YOU HAD

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    Heart disease? *

    YesNo

    Heart attack, heart defects? *

    YesNo

    Heart murmurs? *

    YesNo

    Rheumatic fever? *

    YesNo

    Stroke, hardening of arteries? *

    YesNo

    High blood pressure? *

    YesNo

    Asthma, TB, emphysema, other lung diseases? *

    YesNo

    Hepatitis, other liver disease? *

    YesNo

    Stomach problems, ulcers? *

    YesNo

    Allergies to: drugs, foods, medications, latex? *

    YesNo

    Family history of diabetes, heart problems, tumors? *

    YesNo

    HIV+/AIDS *

    YesNo

    Tumors, cancer? *

    YesNo

    Arthritis, rheumatism? *

    YesNo

    Eye diseases? *

    YesNo

    Skin diseases? *

    YesNo

    Anemia? *

    YesNo

    VD (syphilis or gonorrhea)? *

    YesNo

    Herpes? *

    YesNo

    Kidney, bladder disease? *

    YesNo

    Thyroid, adrenal disease? *

    YesNo

    Diabetes? *

    YesNo

     

    DO YOU HAVE OR HAVE YOU HAD

    ( * ) Marks field are mandatory to fill out

    Psychiatric care? *

    YesNo

    Radiation treatments? *

    YesNo

    Chemotherapy? *

    YesNo

    Prosthetic heart valve? *

    YesNo

    Artificial joint? *

    YesNo

    Hospitalization? *

    YesNo

    Blood transfusions? *

    YesNo

    Surgeries? *

    YesNo

    Pacemaker? *

    YesNo

    Contact lenses? *

    YesNo

     

    ARE YOU TAKING

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    Recreational drugs? *

    YesNo

    Drugs, medications, over-the-counter medicines
    (including Aspirin), natural remedies? *

    YesNo

    Tobacco in any form? *

    YesNo

    Alcohol? *

    YesNo

     

    WOMEN ONLY

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    Are you or could you be pregnant or nursing? *

    YesNo

    Taking birth control pills? *

    YesNo

     

    ALL PATIENTS

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    Do you have or have you had any other diseases or medical problems NOT listed on this form? If so, please explain *

    To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.

    Patient Name *

    Date *