Medical History

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MEDICAL HISTORY

Patient's Full Name(*)

Please let us know the Patient's name.

Patient's Email(*)

Please indicate the Patient's Email Address

Patient's Date of Birth(*)

Please provide the Patient's Birthday.

Are You Under A Doctor's Care & Why?(*)

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Please let us know if you are under a doctor's care and why

Doctor Name

Doctor Address

Please let us know the previous Dentist street address.

Doctor Street Address 2

Please let us know the Previous Dentist street address 2 (suite number or building number)

Doctor City

Please indicate the Previous Dentist City

Doctor State

Please select a Previous Dentist State

Doctor Zip Code

Please indicate the Previous Dentist Zip Code

QUESTIONNAIRE

When was your last complete physical exam ?(*)

When was your last complete physical exam?

Are you taking any medication or substances?(*)

YesNo Please Choose whether you are taking any medication or substances?

List all Medications and/or Substances taking

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Please let us know the list of all medications and/or substances?

Do you routinely take health related substances?
(vitamins, herbal supplements, natural products)(*)

YesNo Please Choose whether you routinely take health-related substances?

Are you allergic to any medications or substances?(*)

YesNo Please choose if are you allergic to any medications or substances?

List Medication and/or Substance List that you are allergic to

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Please list what you are allergic to regarding medications or substances?

Do you have any other allergies or hives?(*)

YesNo Do you have any other allergies or hives?

Any problems with penicillin, antibiotics, anesthetics or other medications?(*)

YesNo Please choose if you have any problems with penicillin, antibiotics, anesthetics or other medications?

Are you sensitive to any metals or latex?(*)

YesNo Are you sensitive to any metals or latex?

Are you pregnant or suspect you may be?(*)

YesNo Are you pregnant or suspect you may be?

Do you use any birth control medications?(*)

YesNo Do you use any birth control medications?

Treated for or been told you might have heart disease?(*)

YesNo Have you ever been treated for or been told you might have heart disease?

Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?(*)

YesNo Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?

Have you ever had rheumatic fever?(*)

YesNo Have you ever had rheumatic fever?

Are you aware of any heart murmurs?(*)

YesNo Are you aware of any heart murmurs?

Do you have high or low blood pressure?(*)

HighLowGood Do you have high or low blood pressure?

Have you ever had a serious illness or major surgery?(*)

YesNo Have you ever had a serious illness or major surgery?

Please explain your serious illness or major surgery?

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Have you ever had a serious illness or major surgery? explained

Do you smoke , chew, use snuff or any other forms of tobacco?(*)

YesNo Do you smoke, chew, use snuff, or any other forms of tobacco?

Regularly consume more than one or two alcoholic beverages a day?(*)

YesNo Do you regularly consume more than one or two alcoholic beverages a day?

Ever taken Fosamax, Zometa, Aredia or other oral or intravenous treatment (bisphosphonates ) for bone tumors, excessive calcium in your blood, or osteoporosis?(*)

YesNo Have you ever taken Fosamax, Zometa, Aredia, or any other oral or intravenous treatment (bisphosphonates ) for bone tumors, excessive calcium in your blood, or osteoporosis?

Do you have inflammatory diseases, such as arthritis or rheumatism?(*)

YesNo Do you have inflammatory diseases, such as arthritis or rheumatism?

Do you have any artificial joints/prosthesis?(*)

YesNo Do you have any artificial joints/prosthesis?

Do you have any blood disorders, such as anemia, leukemia, etc?(*)

YesNo Do you have any blood disorders, such as anemia, leukemia, etc?

Have you ever bled excessively after being cut or injured?(*)

YesNo Have you ever bled excessively after being cut or injured?

Do you have any stomach problems?(*)

YesNo Do you have any stomach problems?

Do you have any kidney problems?(*)

YesNo Do you have any kidney problems?

Do you have any liver problems?(*)

YesNo Do you have any liver problems?

Are you diabetic?(*)

YesNo Are you diabetic?

Do you have fainting or dizzy spells?(*)

YesNo Do you have fainting or dizzy spells?

Ever had radiation, or chemo for another condition?(*)

YesNo Have you ever had radiation treatment, chemo treatment for tumor, growth or other conditions?

Do you have asthma?(*)

YesNo Do you have asthma?

Do you have epilepsy or seizure disorders?(*)

YesNo Do you have epilepsy or seizure disorders?

Venereal or any sexually transmitted disease?(*)

YesNo Do you or have you had venereal or any sexually transmitted disease?

Have you tested HIV positive?(*)

YesNo Have you tested HIV positive?

Do you have AIDS?(*)

YesNo Do you have AIDS?

Have you had or do you test positive for hepatitis?(*)

YesNo Have you had or do you test positive for hepatitis?

Do you or have you had T.B.?(*)

YesNo Do you or have you had T.B.?

Do you habitually use controlled substances?(*)

YesNo Do you habitually use controlled substances?

Have you had psychiatric treatment?(*)

YesNo Have you had psychiatric treatment?

Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?(*)

YesNo Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?

Do you have any disease condition, or problem not listed?(*)

YesNo Do you have any disease condition, or problem not listed?

Please explain the disease condition, or problem not listed

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Please explain the disease condition, or problem not listed

Anything else about your health not covered in this form?

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Anything else about your health not covered in this form?

Would you like to speak to the Doctor privately?(*)

YesNo Would you like to speak to the Doctor privately about any problem?

SIGNATURE

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE

Patient or Guardian Printed Name(*)

PATIENT'S OR GUARDIAN'S SIGNATURE(*)

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Help Us Fight Spam (Input only Lower Case Letters Even if They Show As Capitals)(*)

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