Home Medical History Form Medical History Form First Name(Required) Last Name(Required) Phone(Required)Email(Required) Current physical health is :(Required) Good Fair Poor 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 Drug Abuse Yes No Memory Loss Yes No Acid Reflux Yes No Emphysema Yes No Mitral Valve Prolapse Yes No Alcohol Abuse Yes No Epilepsy Yes No Occlusal Appliance Yes No Arthritis Yes No Glaucoma Yes No Pacemaker Yes No Artificial Joints Yes No Headaches Yes No Psychiatric Care Yes No Artificial Valves Yes No Heart Murmur Yes No Radiation Treatment Yes No Asthma Yes No Heart Surgery Yes No Rheumatic Fever Yes No Blood Transfusion Yes No Hepatitis Yes No Sinus Problems Yes No Cancer Yes No HIV+/AIDS Yes No Snoring/Sleep Apnea Yes No Chemotherapy Yes No High Blood Pressure Yes No Stroke Yes No Congenital Heart Defect Yes No Hearing Impaired Yes No Thyroid Problems Yes No Depression Yes No Kidney Problems Yes No Tuberculosis (TB) Yes No Diabetes Yes No Liver Disease Yes No Ulcers Yes No Anxiety Yes No High Cholesterol Yes No Vertigo Yes No Autism Yes No If you answered YES to any of the questions above, please explain: Tobacco Use? What form of tobacco and how frequent? 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 Explain Any complications following dental treatment? History of “deep cleaning” Scaling and Root Planning or Periodontal Surgery? Anything else you would like us to know? Consent(Required) 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.(Required)Date(Required) MM slash DD slash YYYY
