Medical History Forms

HEALTH HISTORY

Patient Name:

Date:

Do YOU (not family members) have currently, or a history of the following:

Abnormal bleeding or bruising

Yes No

If YES, please provide details

Artificial Joints

Yes No

If YES, please provide joint replaced and year of surgery

Asthma:

Yes No

If YES, please provide details

Auto Immune Disease:

Yes No

If YES, please provide details

Cancer (other than skin):

Yes No

If YES, please provide details

Diabetes:

Yes No

If YES, please provide details

Glaucoma:

Yes No

If YES, please provide details

Heart Conditions/Heart Valve Abnormality

Yes No

If YES, please provide details

HIV or Aids

Yes No

If YES, please provide details

Hypertension (High Blood Pressure)

Yes No

If YES, please provide details

Do you require antibiotics before dentistry?

Yes No

If YES, why?

Hepatitis or Other Liver Disease:

Yes No

If YES, please provide details

Kidney Disease:

Yes No

If YES, please provide details

Lung Disease

Yes No

If YES, please provide details

Pregnant or Nursing:

Yes No

If YES, please provide details

Pacemaker:

Yes No

If YES, please provide details

Psychological or Psychiatric Disorder:

Yes No

If YES, please provide details

Severe blistering sunburn

Yes No

If YES, provide estimate age and body location

Skin Cancer

Yes No

If YES, provide type, body location, year diagnosed and treatment received

Thyroid Disease:

Yes No

If YES, please provide details

FAMILY HISTORY

Please only include IMMEDIATE family history. Immediate Family consists of: Grandparents, Parents, Siblings, and Children

If YES, please provide who (i.e. Maternal Grandmother, etc)

Auto Immune Disease (lupus, rheumatoid arthritis, etc)

Yes No

If YES, please provide details

Eczema

Yes No

If YES, please provide details

Psoriasis

Yes No

If YES, please provide details

Malignant Melanoma

Yes No

If YES, provide age when diagnosed if known, and if survived

Non-Melanoma Skin Cancer

Yes No

If YES, who and what type

Preferred Pharmacy (name and location) :

SOCIAL HISTORY

Do YOU currently, or have a history of the following?

Alcohol Use

Yes No

If YES, please provide frequency

Tobacco Use

Yes No

If YES, please provide frequency

Going to Tanning Salons

Yes No

If YES, please provide ages and frequency

Working Outdoors (i.e. lifeguard, landscaping, etc.)

Yes No

If YES, please provide ages

Where did you live from birth to age 20?

ALLERGIES AND MEDICATIONS

List all known allergies to medications and the reaction you had

None

List current medications (please include birth control implants or IUDs if applicable)

None

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