Medical Health History Form
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1
2MEDICAL HEALTH HISTORY
NAME ___________________________ #___________
Welcome! So that we may provide you with the best possible care, it is important that you tell all dental personnel involved in your treatment about the
general state of your health. Please complete this medical history form. This information is, of course, confidential.
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Name ____________________________________________________________________ Date of Birth _________ Age: ______
Male
Female
Weight ______________Height _______________ If Patient is a Minor _______________________________________________________________
(Name of Parent/Guardian)
MEDICAL HISTORY
Name and address of physician _______________________________________________________________________________________________
When was your last physical examination? _______________________________________________________________________________________
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Are you now under the care of a physician?
Yes
No
If yes, for what reason? ______________________________________________________________________________________________
Are you presently taking any medications/drugs/pills?
Please list: ________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Are you allergic (or have an adverse reaction) to:
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Penicillin
Codeine
Local Anesthetic
None
Other _______________________________
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Aspirin
Other antibiotics
Are you sensitive or allergic to latex? Have you experienced itching, rash or wheezing after using latex gloves or handling a balloon? Have you had any
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unusual or unexplained reactions during a surgical procedure? No
Yes
Explain _________________________________________________
_________________________________________________________________________________________________________________________
Do you have, or have you ever had any of the following: (yes or no)
Please check each box individually
Yes No
Yes No
Yes No
Yes No
Yes No
Heart Disease / Surgery
Tuberculosis
Liver disease
Sinus trouble
Neurological disorders
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Heart murmur
Lung disease
Learning disability
Cancer
Prosthetic implants
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Heart pacemaker
Diabetes
Arthritis/Rheumatism
Tumors
Artificial joint
q q
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Rheumatic fever
Epilepsy
Cortisone medicine
Chemotherapy
Venereal disease
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Rheumatic heart disease
Anemia
Prolonged bleeding
Radiation therapy
HIV positive/AIDS/ARC
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Congenital heart defects
Thyroid problems
Hemophilia
Stroke
Hearing impaired
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Artificial heart valve
Chemical dependency
Sickle Cell Disease
Glaucoma
Organ transplant
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Mitral valve prolapse
Kidney problems
Fainting spells
Psychiatric care
Removal of Spleen
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Abnormal blood pressure
Hepatitis (circle one)
Asthma
Anorexia
Alcohol addiction
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Ulcers
Type A B C
Emphysema
Bulimia
Drug dependency
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Scarlet Fever
Cognitive Disability
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Do you currently smoke or use the following tobacco products?
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cigarettes
cigars
pipe
chew
none
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Have you used tobacco products in the past?
Yes
No
How long ago? _______________
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Do you drink alcoholic beverages?
Yes
No
How much? _______________
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WOMEN: Are you pregnant?
Yes
No
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Do you take birth control medications? Yes
No
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Have you had any other serious illness, hospitalization or accident?
Yes
No
If yes, please explain ________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
DR COMMENTS
____________________________
____________
DR SIGNATURE
DATE
BP ____________________
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best
of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release
such information to you. I will notify the doctor of any changes in my health or medication.
Patient signature ___________________________________________________________
Date ____________________________________
(PARENT/GUARDIAN OF A MINOR)
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