Medical History Form
ADVERTISEMENT
1MEDICAL HISTORY FORM
PATIENT NAME:__________________________
DATE OF BIRTH _________________________
PHONE:(_______)_______________________________
NAME OF DENTIST:___________________ _________
ADDRESS _______________________ ____________
ADDRESS:____________________________________
CITY:_____________
E-mail Address: _____________________________
PHONE:(______)_______________________________
Emergency Contact
NAME: ________________________________________
PHONE:(______)_______________________________
Where did you hear about us : ________________________________________________
Please circle YES or NO to the following: The answers are for the office records only and will be considered confidential.
YES
NO
Are you presently under a physician’s care? If so, for what_______________________________________
YES
NO
Have you ever been advised to premedicate with antibiotics for dental appointments?
YES
NO
Has there been any change in your health in the past year? If yes, please explain:____________________
YES
NO
Women – Are you pregnant?
Do you have or have had any of the following?
YES
NO
Heart Disease, Murmur, Angina, Attack
YES
NO
Rheumatic Fever
YES
NO
Mitral Valve Prolapse
YES
NO
Hepatitis (yellow jaundice)
YES
NO
Stroke
YES
NO
Hepatitis B
YES
NO
Do you wear a pacemaker?
YES
NO
Hepatitis C
YES
NO
Do you have cardiac valve prosthesis?
YES
NO
High or low blood pressure
YES
NO
Jaundice or liver diseases
YES
NO
Diabetes
YES
NO
HIV or AIDS
YES
NO
Tuberculosis
YES
NO
Venereal Disease
YES
NO
Do you have any artificial prosthesis?
YES
NO
Chest pains or shortness of breath
YES
NO
Cancer
YES
NO
Arthritis
YES
NO
Medical radiation treatments
YES
NO
Any other medical conditions: If so, what_____________________________________________________
Are you allergic to or react adversely to:
YES
NO
Penicillin
YES
NO
Ibuprofen
YES
NO
Aspirin
YES
NO
Antibiotics
YES
NO
Latex
YES
NO
Other____________________________
Are you presently taking any of the following medications?
YES
NO
Antibiotics
YES
NO
Birth control
YES
NO
Medication for high blood pressure
YES
NO
Heart medication
YES
NO
Medication for Diabetes
YES
NO
Other____________________________
YES
NO
I hereby give my permission to have my or my child’s diagnostic records (radiographs, photos, study
models) used for teaching, diagnostic and marketing purposes.
DATE:_________________ SIGNATURE:______________________________________________________
DATE:_________________ DR. SIGNATURE:__________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical