Home Medical History Form Medical History Form Order Number First Name * Last name * Email * Phone * Current physical health is : * Good Fair Poor Are you currently under the care of a physician? * Yes No If YES, Please explain Physician Name Clinic Name Are you allergic to any of the following? Amoxicillin Erythromycin Penicillin Aspirin Jewelry Sulfa Drugs Codeine Latex Dental Anesthetics Other other : Please list all current medications: Do you have or have you experienced any of the following? Abnormal Bleeding * Yes No Acid Reflux * Yes No Alcohol Abuse * Yes No Arthritis * Yes No Artificial Joints * Yes No Asthma * Yes No Blood Transfusion * Yes No Cancer * Yes No Chemotherapy * Yes No Anxiety * Yes No Congenital Heart Defect * Yes No Depression * Yes No Diabetes * Yes No Drug Abuse * Yes No Emphysema * Yes No Epilepsy * Yes No Glaucoma * Yes No Headaches * Yes No Heart Murmur * Yes No Heart Surgery * Yes No Hepatitis * Yes No HIV/AIDS * Yes No High Blood Pressure * Yes No Hearing Impaired * Yes No Kidney Problems * Yes No Liver Disease * Yes No Memory Loss * Yes No Mitral Valve Prolapse * Yes No Occlusal Appliance * Yes No Pacemaker * Yes No Psychiatric Care * Yes No Radiation Treatment * Yes No Rheumatic Fever * Yes No Sinus Problems * Yes No Snoring * Yes No Stroke * Yes No Thyroid Problems * Yes No Tuberculosis (TB) * Yes No Ulcers * Yes No Vertigo * Yes No Hepatitis Type : Cancer Others : Has any doctor recommended pre-medication with antibiotics before dental appointments for any reason? Explain: * List any serious medical condition(s) you have experienced Women: Are you pregnant now? How many months? Are you happy with the appearance of your smile? * Yes No If NO, please explain Any complications following dental treatment? * Anything else you would like us to know? I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need. Waseca Family Dentistry Privacy Policy * Date
