Medical History Form

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Patient’s Name______________________________________________Dr.___________________________
Answers to the following questions are for our records only and will be considered confidential.
Please answer all questions by filling in the blank spaces or circling the appropriate responses.
If you are filling out this form for another adult or child, please indicate your relationship to that adult or child.
Name______________________________________ Relationship___________________________________
1. My last physical examination was on _________________________________________________________
My last dental examination was on __________________________________________________________
2. Physician’s name: Dr. ___________________________ Phone (____)______________ City ____________
3. Previous Dentist: Dr. ___________________________ Phone (____)______________ City ____________
4. Are you in good health? …………………………………………………………………………..
Yes
No
5. Has there been any change in your general health within the past year? …………………………
Yes
No
6. Are you now under the care of a physician?……………………………………………………..
Yes
No
7. Are you being treated for any problem?………………………………………………………...…
Yes
No
8. Have you been hospitalized or had any serious illness or operation?……………………………
Yes
No
If so, what was the problem? _______________________________________________________________
9. Are you pregnant?…………………………………………………………………………………
Yes
No
10. List any medications or drugs you are taking:________________________________________________________________________
11.
List any medications or drugs you cannot
take: ________________________________________________
12.
Are you currently taking any form of blood thinners? ie plavix, coumadin, pradaxa, aspirin,
__________
13. *Do you need to
pre-medicate
before appointments? Yes ______ No ______
Have you ever had any of the following? (Please check the appropriate answers)
Yes
No
Yes
No
Yes
No
___
___ Rheumatic fever
___
___ Arthritis
___
___ Bruise easily
___
___ Heart disease
___
___ Neurological disorder
___
___ Been told you snore
___
___ Pacemaker
___
___ Mental disturbances
___
___ Bleeding disorder
___
___ Prosthetic heart valves ___
___ Fainting spells
___
___ Hemophilia
___
___ Joint replacements
___
___ Nervousness
___
___ Anemia
___
___ Hydrocephalic shunt
___
___ Seizures or epilepsy
___
___ Sickle cell anemia
___
___ Dialysis shunt
___
___ Stomach ulcers
___
___ Cancer
___
___ High Blood Pressure
___
___ Chronic Fatigue
___
___ Acid Reflux/Gerd
___
___ High Cholesterol
___
___ Kidney disease
___
___ Any tumors
___
___ Low blood pressure
___
___ Kidney transplant
___
___ Cold sores
___
___ Chest pain upon exertion ___
___ Diabetes
___
___ Alcohol usage
___
___ Shortness of breath
___
___ Dry mouth
___
___ Drug Abuse
___
___ Swollen ankles
___
___ Frequent thirst or urination ___
___ Birth control pills
___
___ Allergies
___
___ Other metabolic disorders ___
___ Problems with menstruation
___
___ Asthma
___
___ Abnormal bleeding
___
___ Thyroid disorder
___
___ Hives or skin rash
___
___ Hay fever
___
___ mood disorder/depression
___
___ have trouble sleeping
___
___ sleep apnea
___
___ heart attack
Has any family member (parent, sibling, grandparent) ever had any of the following? Please check the appropriate answers.
___ Cancer
___ Sleep disorder
___ Diabetes
___ Thyroid disorder
___ Father snores
___ Heart disease
___ High blood pressure
___ Stroke
___ Mother snores

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