(512) 264-9333


Crowns, Bridges, Dentures, Veneers, Cosmetic Dentistry, Preventive Dentistry

Medical History


Please let us know the Patient's name.
Please indicate the Patient's Email Address
Please provide the Patient's Birthday.


Please let us know if you are under a doctor's care and why
Please let us know the previous Dentist street address.
Please let us know the Previous Dentist street address 2 (suite number or building number)
Please indicate the Previous Dentist City
Please select a Previous Dentist State
Please indicate the Previous Dentist Zip Code


When was your last complete physical exam?
Please Choose whether you are taking any medication or substances?


Please let us know the list of all medications and/or substances?
Please Choose whether you routinely take health-related substances?
Please choose if are you allergic to any medications or substances?


Please list what you are allergic to regarding medications or substances?
Do you have any other allergies or hives?
Please choose if you have any problems with penicillin, antibiotics, anesthetics or other medications?
Are you sensitive to any metals or latex?
Are you pregnant or suspect you may be?
Do you use any birth control medications?
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?
Have you ever had rheumatic fever?
Are you aware of any heart murmurs?
Do you have high or low blood pressure?
Have you ever had a serious illness or major surgery?


Have you ever had a serious illness or major surgery? explained
Do you smoke, chew, use snuff, or any other forms of tobacco?
Do you regularly consume more than one or two alcoholic beverages a day?
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?
Do you have any artificial joints/prosthesis?
Do you have any blood disorders, such as anemia, leukemia, etc?
Have you ever bled excessively after being cut or injured?
Do you have any stomach problems?
Do you have any kidney problems?
Do you have any liver problems?
Are you diabetic?
Do you have fainting or dizzy spells?
Have you ever had radiation treatment, chemo treatment for tumor, growth or other conditions?
Do you have asthma?
Do you have epilepsy or seizure disorders?
Do you or have you had venereal or any sexually transmitted disease?
Have you tested HIV positive?
Do you have AIDS?
Have you had or do you test positive for hepatitis?
Do you or have you had T.B.?
Do you habitually use controlled substances?
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?
Do you have any disease condition, or problem not listed?


Please explain the disease condition, or problem not listed


Anything else about your health not covered in this form?
Would you like to speak to the Doctor privately about any problem?



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