Medical History Form
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1Medical History
Patient’s Name__________________________________
Phone (H)_____________________
Address
_________________________________
Cell
_____________________
_________________________________
Email_________________________
Responsible Party of Account_______________________
Referred By ____________________
Dental Insurance_________________________________
Employer______________________
Subscriber #____________________________________
Date of Birth ___________________
SS# of Subscriber________________________________
Please share with us the names of your family members_____________________________________
1. Are you having pain or discomfort at this time?-------------------------------
Yes
No
2. Do you feel very nervous about having dental treatment?------------------
Yes
No
3. Have you had a bad experience in a dentist office? -------------------------
Yes
No
4. Have you been a patient in the hospital during the last two years?------
Yes
No
5. Have you been under a doctors care during the past two years?--------
Yes
No
6. Have you taken medicine or drugs during the past two years?-----------
Yes
No
7. Are you allergic to or made sick by;
Penicillin, Aspirin, Codeine, or any other drugs or medication -----------
Yes
No
8. Have you ever had any excessive bleeding requiring special treatment? ------- Yes
No
9. Circle any of the following that you have or have had in the past:
Heart Failure
Stroke
X-Ray or Cobalt Tx
Blood Transfusion
Heart Disease or Attack
Kidney Trouble
Chemo
Drug Addiction
Angina Pectoris
Ulcers
Arthritis
Hemophilia
High Blood Pressure
Mitral Valve Prolapse
Rheumatism
Venereal Disease
Heart Murmur
Emphysema
Cortisone Medicine
Cold Sores
Congenital Heart Lesions
TB
pain in Joint
Epilepsy or Seizure
Scarlet Fever
Asthma
Organ Transplant
Fainting/Dizzy Spells
Artificial Heart Valve
Hay Fever
Aids
Nervousness
Heart Pacemaker
Sinus Trouble
Hepatitis A (infec)
Psychiatric Treatment
Heart Surgery
Allergies or Hives
Hepatitis B (ser)
Sickle Cell Disease
Artificial Joint
Diabetes
Liver Disease
Bruise Easily
Anemia
Thyroid Disease
Yellow Jaundice
10. When walking upstairs or taking walks do you have to stop because of shortness of breath or
become very tired?------------------------------------------------------------------------------
Yes
No
11. Do your ankles swell during the day?-------------------------------------------------
Yes
No
12. Do you use more then 2 pillows to sleep?-------------------------------------------
Yes
No
13. Have you lost or gained more then 10 pounds in the past year?--------------
Yes
No
14. Do you ever wake up from sleep short of breath?---------------------------------
Yes
No
15. Are you on a special diet?---------------------------------------------------------------
Yes
No
16. Has your medial doctor ever said you have cancer or tumor?----------------
Yes
No
17. Do you have any disease not listed? Yes No If so please name_______________________
18. Women:
Are you pregnant?--------------------------------------------------
Yes
No
Are you practicing birth control?----------------------------------
Yes
No
Do you anticipate becoming pregnant?---------------------------
Yes
No
19. Please list all medications currently taking
All of the proceeding statements are true, if any changes occur, I will inform the dentist at my next
appointment.
Date_______________________
Signature____________________________________
Please read and sign back of form
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