Medical History Form printable pdf download

Medical History

Current Medications /dose

: ....................................................................................................... _

Patient Name

Circle

______________________

1.Where are you having any pain or discomfort at this time? .......................................................

______________________

....................................................................................................................................................

______________________

2.Have you been a patient in the hospital during the past two years? ........................... YES NO

______________________

3.Have you been under the care of a medical doctor during the past two years? ......... YES NO

______________________

4.Have you taken medicine or drugs during the past two years? .................................. YES NO

______________________

5.Are you allergic to (Le. itching, rash, swelling of hands, feet or eyes) or made sick

______________________

by penicillin, aspirin, codeine or any drugs or medications? ...list below .............YES NO

______________________

6.Have you ever had excessive bleeding or been on Blood Thinners... .....................

YES NO

______________________

7.When you walk up stairs or take a walk, do you ever have to stop because of pain

______________________

in your chest, or shortness of breath, or because you are very tired? ................. YES NO

______________________

8.Do you ankles swell during the day? .......................... : .............................................. YES NO

______________________

9.Are you a smoker and How much per day? ................ ................................................ YES NO

______________________

10.Have you lost or gained more than 10 pounds in the past year? ................................ YES NO

______________________

11.Do you ever wake up from sleep short of breath? ................................................... YES NO

______________________

Medication Allergies

12.Are you on a special diet? ..........................................................................................YES NO

______________________

13.Do you have a history of recreational drugs or drug abuse?......................................YES NO

13.Has your medical doctor ever said you have a cancer or tumor? ................................YES NO

______________________

14.Women: Are you pregnant now? ................................................................................YES NO

______________________

Do you anticipate becoming pregnant? ................................................... YES NO

______________________

15. Circle Yes or No for each and every of the following which you have had or have at present:

______________________

Heart Failure

Yes No

Emphysema

Yes No

AIDS

Yes No

______________________

Yes No

Heart Disease or Attack

Cough

Hepatitis (infectious)

______________________

Angina Pectoris

Yes No

Tuberculosis (TB

Yes No

Hepatitis (serum)

______________________

Yes No

High Blood Pressure

Yes No

Asthma

Yes No

Liver Disease

______________________

Yes No

______________________

Heart Murmur

Yes No

Hay Fever

Yes No

Yellow Jaundice

Yes No

______________________

Rheumatic Fever

Yes No

Sinus Trouble

Yes No

Blood Transfusion

Yes No

______________________

Yes No

Congenital Heart Lesions

Allergies or Hives

Drug Addiction

______________________

Scarlet Fever

Yes No

Diabetes

Yes No

Hemophilia

Yes No

______________________

Yes No

Artificial Heart Valve

Thyroid Disease

Venereal Disease

______________________

Heart Pacemaker

Yes No

Radiation Treatment

Yes No

Cold Sores

Yes No

______________________

Heart Surgery

Yes No

Chemotherapy

Yes No

Genital Herpes

Yes No

______________________

Yes No

Artificial Joint

Arthritis

Epilepsy or Seizures

Anemia

Yes No

Rheumatism

Yes No

Fainting/Dizzy Spells

Yes No

Stroke

Cortisone Medicine

Nervousness

Kidney Trouble

Yes No

Glaucoma

Yes No

Psychiatric Treatment

Yes No

Ulcers

Yes No

Pain in Jaw Joints

Yes No

Bruise Easily

Yes No

16. Please write if have or had any disease, condition, or problem not listed ________________________________________

_____________________________________________________________________________________________________

Date of last Complete Physical incl. blood tests:____________Problems Observed ___________________________________

Physicians Name:___________________________ Medical Grp:____________________________ Phone _______________

Specialist:_________________________________ Medical Grp:____________________________ Phone _______________

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or if my medicineschange, I will inform

the dentist at the next appointment with fail. Changes may also be faxed, phoned, or emailed to the dentist as well.

____________ ________________________________

______________________________________________

Date

Dentists Signature

Signature of Patient, Parent or Guardian

Do Not Write In This Area

Medical History / Physical Evaluation Update

Doctor Only

Date

Addition

Date

Addition

______ _____________________________________ ______ _________________________________________________

Medical History Form

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