Medical History Form

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  • Date of Last Health Care Examination:*

    Presently, Are You Under Medical Care:*

  • For What:

  • Name of Physician:*

    Phone:*

  • Are you taking any Medication:*

    Are you allergic to any Drugs:*

  • Which:

    Please Enter Yes or No

    Do you have Or Have you Ever Had

  • Asthma:*

    Artificial Joints:*

  • Heart Trouble:*

    AIDS/HIV:*

  • Abnormal Blood Pressure:*

    Venereal Disease:*

  • Diabetes:*

    Abnormal Bleeding:*

  • Epilepsy:*

    Ulcer:*

  • Rheumatic Fever:*

    Cancer or Tumor:*

  • Hear Murmur:*

    Pacemaker:*

  • Major Operations:*

    Anemia:*

  • Are you Allergic To:

  • Penicillin:*

    Local Anesthetic:*

  • Codeine:*

    Wome: Are you Pregnant:*

  • Dental History

    Date of Last Exam:*

    Purpose:*

  • Are you Having Discomfort at This Time:

  • Have you ever had :

    Fluoride Treatment:*

    Trouble From Dental Extraction:*

  • Pain in Teeth:*

    Dleeding Gums:*

  • Periodontal Therapy:*

  • Have you ever had any complications following Dental Treatment?:*

  • if Yes, Please Explain:*

    Do you clench or Grind your Teeth:*

  • Are you happy with the Appearance of your Teeth:*

    Comment:*

  • To the best of my knowledge, all of the proceeding answers are information provided are true and corrent. If I ever have any change in my health, I will inform the doctor at the next appointment without fail.