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Patient Forms
Medical History
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*
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First Name
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Last Name
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Phone
*
Email
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Have you been seen at a dental clinic in the last 5 years years?
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Yes
No
Current physical health is :
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Good
Fair
Poor
Explain
Physician Name
Clinic Name
Are you allergic to any of the following?
Amoxicillin
Erythromycin
Penicillin
Aspirin
Jewelry
Sulfa Drugs
Codeine
Latex
Dental Anesthetics
Other
Other
Please list all current medications:
Do you have or have you experienced any of the following?
Abnormal Bleeding
Yes
No
Drug Abuse
Yes
No
Memory Loss
Yes
No
Acid Reflux
Yes
No
Emphysema
Yes
No
Mitral Valve Prolapse
Yes
No
Alcohol Abuse
Yes
No
Epilepsy
Yes
No
Occlusal Appliance
Yes
No
Arthritis
Yes
No
Glaucoma
Yes
No
Pacemaker
Yes
No
Artificial Joints
Yes
No
Headaches
Yes
No
Psychiatric Care
Yes
No
Artificial Valves
Yes
No
Heart Murmur
Yes
No
Radiation Treatment
Yes
No
Asthma
Yes
No
Heart Surgery
Yes
No
Rheumatic Fever
Yes
No
Blood Transfusion
Yes
No
Hepatitis
Yes
No
Sinus Problems
Yes
No
Cancer
Yes
No
HIV+/AIDS
Yes
No
Snoring/Sleep Apnea
Yes
No
Chemotherapy
Yes
No
High Blood Pressure
Yes
No
Stroke
Yes
No
Congenital Heart Defect
Yes
No
Hearing Impaired
Yes
No
Thyroid Problems
Yes
No
Depression
Yes
No
Kidney Problems
Yes
No
Tuberculosis (TB)
Yes
No
Diabetes
Yes
No
Liver Disease
Yes
No
Ulcers
Yes
No
Anxiety
Yes
No
High Cholesterol
Yes
No
Vertigo
Yes
No
Autism
Yes
No
If you answered YES to any of the questions above, please explain:
Tobacco Use?
What form of tobacco and how frequent?
Has any doctor recommended pre-medication with antibiotics before dental appointments for any reason? Explain:
List any serious medical condition(s) you have experienced
Women :
Are you pregnant now?
How many months?
Are you happy with the appearance of your smile?
Yes
No
Explain
Any complications following dental treatment?
History of “deep cleaning” Scaling and Root Planning or Periodontal Surgery?
Anything else you would like us to know?
Consent
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I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need. Here
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Date
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MM slash DD slash YYYY
