Patient Medical History Form

First Name

Last Name

Email

Phone Number

General Health:

ExcellentGoodFairPoor

Under a physician's care now?

YesNo

Any hospitalization in the past 5 years?

YesNo

If you answered "yes" above, please explain.

Any serious illnesses/surgeries?

YesNo

If you answered "yes" above, please explain.

Use tobacco in any form?

YesNo

If you answered "yes" above, please explain.

Is pre-medication required before dental visits due to heart condition or artificial joint?

YesNo

Taking any prescription or daily OTC medications/drugs?

YesNo

If yes, list details in the Medication Section.

Currently nursing?

YesNo

Currently pregnant?

YesNo

If you answered "yes" above, what is your due date?

Do you know of any reason why routine dental procedures might pose a risk to you, our staff, or other patients?

YesNo

If you answered "yes" above, please explain.

Is there anything important about your medical condition we have not asked?

YesNo

If you answered "yes" above, please explain.

ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

If you answered "Other" above, please explain.

ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):

If you answered "Other" above, please explain.

ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

Please list any additional medications.