Medical History Patient Name* First Last Have you ever had any of the following medical conditions? AIDS / HIV Positive Anemia Artificial Heart Valve Blood Disease Bruise Easily Chest Pains Convulsions Drug Addiction Epilepsy or Seizures Fainting Spells / Dizziness Frequent Headaches Hay Fever Heart Pacemaker Hepatitis A High Blood Pressure Hypoglycemia Leukemia Lung Disease Osteoporosis Pregnant/Trying to get pregnant Scarlet Fever Sinus Trouble Stroke Thyroid Disease Tumors or Growths Yellow Jaundice Alzheimer`s Disease Angina Artificial Joint Blood Transfusion Cancer Cold Sores/Fever Blisters Cortisone Medicine Easily Winded Excessive Bleeding Frequent Cough Genital Herpes Heart Attack/Failure Heart Trouble/Disease Hepatitis B or C High Cholesterol Irregular Heartbeat Liver Disease Mitral Valve Prolapse Pain in Jaw Joints Psychiatric Care Recent Weight Loss Rheumatic Fever Shingles Spina Bifida Swelling of Limbs Tonsillitis Ulcers Anaphylaxis Arthritis/Gout Asthma Breathing Problem Chemotherapy Congenital Heart Disorder Diabetes Emphysema Excessive Thirst Frequent Diarrhea Glaucoma Heart Murmur Hemophilia Herpes Hives or Rash Kidney Problems Low Blood Pressure Nursing Parathyroid Disease Radiation Treatments Renal Dialysis Rheumatism Sickle Cell Disease Stomach/Intestinal Disease Taking oral contraceptives Tuberculosis Venereal Disease Do you have any other health problems?YesNoAre you allergic to any of the following? Allergic to Acrylic Allergic to Latex Allergic to Sulfa Drugs Allergic to Aspirin Allergic to Local Anesthetics Senstive to stevia and artificial sweetner Allergic to Codeine Allergic to Metal Allergic to Penicillin Do you have other allergies not listed above?YesNoPlease ListPlease List the Medications, Pills or Drugs You Are Currently TakingAre you taking or have you ever taken medications for osteoporosis?*YesNoDo you have a physician (medical doctor)?*YesNoHave you been hospitalized or had a major surgery?*YesNoHave you ever had a serious head or neck injury?*YesNoDo you use tobacco products?*YesNoDo you use controlled substances?*YesNoWomen: are you pregnant or do you think you may be pregnant?YesNoWomen: Are you nursing?YesNoIs there any other information about your health we should know?Consent* To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.Signature*Relationship to the patientName if not the patient
