Patient Medical History Form
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2PREHN DENTAL OFFICE
PATIENT MEDICAL HISTORY
PATIENT NAME:_______________________________________ DATE: ________________________
FAMILY PHYSICIAN:___________________________
ANY SPECIALIST?:_____________
Do we have your permission to contact your personal physician if the need arises?
Yes______No______
Are you currently under a Medical Doctors care for a physical condition? Yes______No______
Please explain:_________________________________________________________________________
_____________________________________________________________________________________
Pharmacy:_________________________________________
List All Medications: Non-Prescription & Prescription
Allergies:
Y N
Y N
Y N
Aspirin
Erythromycin
Metals
Codeine
Jewelry
Penicillin
Dental
Latex
Tetracycline
Anesthetics
Other:________________________________________
_____________________________________________
Miscellaneous:
For Women Only:
Y N
Y N
Do You Smoke or Use Tobacco?
Are you taking birth control pills?
Are you pregnant? # of weeks_____
Height:_____’_____”___ Weight:__________________
Are you nursing?
Office Use: BP________/__________Heart Rate:________________
Have you lost/gained more than 10 lbs. in the past year?
Conditions: Please check Yes or No to the Following
Y N
Y N
Y N
Y N
Y N
B/4 Dental Appts
Abnornal
Herpes
Emphysema
Hay Fever
Do You Premedicate?
Bleeding
(Any Kind)
Heart
Anemia/Blood
Fever Blisters/
Pneumocystitis
Sinus Problems
Problems
Disease
Cold Sores
Heart
High Blood
Shingles
Ulcers/Colitis
Frequent
Attack
Pressure
Headaches
Heart
Artificial
Malignant
Kidney
Thyroid
Murmur
Joint
Hyperthermia
Problems
Problems
Chest Pain
Hepatitis A
High
Cancer
Sleep Apnea/
Cholesterol
Excessive Snoring
Artificial
Hepatitis B
Alcohol/Drug
Radiation/
TMJ/TMD
Heart Valve
Abuse
Chemotherapy
Problems
Mitral Valve
Hepatitis C
Psychiatric/
Epilepsy/
Arthritis/
Prolapse
Emotional Care
Seizures
Rheumatism
Rheumatic
HIV+ AIDS
Respiratory
Liver Disease
Venereal
Fever
Problems
Disease
Hemophilia
Stroke
Asthma
Tonsils/
Fainting/Dizzy
Adnoids Removed
Spells
Coumadin
Diabetes
Tuberculosis
Eye/Ear
Do You Take
Disorder
Herbs/Vitamins?
I attest these answers to be truthful and as complete as possible.
Signature:____________________________________________________Date:_______________________________
PLEASE COMPLETE THE BACK OF THIS FORM
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Parent category: Medical