Medical History Form
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1Medical History
Date:__________
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 ever had a bad experience in the dental office?
Yes
No
4.
Have you been a patient in the hospital during the past two years?
Yes
No
5.
Have you been under the care of a medical doctor during the past two years?
Yes
No
Physician’s Name___________________________________________________________________________
Address_____________________________________ Phone________________________________________
6.
Have you taken any medicine or drugs during the past two years?
Yes
No
7.
Are you now taking any medications, drugs, or pills?
Yes
No
If yes, please list___________________________________________________________________________
8.
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 tired?
Yes
No
9.
Do your ankles swell during the day?
Yes
No
10. Do you use more than 2 pillows to sleep?
Yes
No
11. Have you lost or gained more than 10 pounds in the past year?
Yes
No
12. Do you ever wake up from sleep short of breath?
Yes
No
13. Are you on a special diet?
Yes
No
14. Has your medical doctor ever said you have a cancer or a tumor?
Yes
No
For Women:
15. Are you pregnant?
Yes
No
if yes, what month? ________________
16. Are you taking birth control pills?
Yes
No
Are you allergic or have reacted adversely to any of the following medications:
Aspirin
Codeine
Nitrous Oxide
Darvon
Demerol
Erythromycin
Tetracycline
Penicillin
Sleeping Pills
Percodan
Other Antibiotics
(Nembutal/ Seconal)
Valium
Local Anesthetic
Sulfa
Scopolamine
(Novocain or Xylocaine)
Are you aware of being allergic to any other medications or substance? Yes
No
If yes, please list: ________________________________________________________________
Circle any of the following which you have had or have at present:
Heart Failure
Cough
Herpes
Heart Disease or Attack
Tuberculosis (TB)
Hepatitis A (infectious)
Angina Pectoris
Asthma
Hepatitis B (serum)
High Blood Pressure
Hay Fever
Liver Disease
Heart Murmur
Sinus Trouble
Yellow Jaundice
Rheumatic Fever
Allergies or Hives
Blood Transfusion
Congenital Heart Lesions
Diabetes
Drug Addiction
Scarlet Fever
Thyroid Disease
Hemophilia
Artificial Heart Valve
X-ray or Cobalt Treatment
Venereal Disease (Syphilis,
Heart Pacemaker
Cancer
Gonorrhea)
Heart Surgery
Chemotherapy (Cancer, Leukemia)
Cold Sores
Artificial Joints (Hip, Knee)
Arthritis
Fever Blisters
Anemia
Rheumatism
Epilepsy or Seizures
Stroke
Cortisone Medicine
Fainting or Dizzy Spells
Kidney Trouble
Glaucoma
Nervousness
Ulcers
Pain in Jaw Joints (TMJ)
Psychiatric Treatment
Cosmetic Surgery
A.I.D.S.
Sickle Cell Disease
Emphysema
HIV positive
Bruise Easily
Do you have any disease, condition, or problem not listed above?
Yes
No
If yes, please list: ________________________________________________________________
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Parent category: Medical