Medical Health History Update

Patient Name

Date of Birth

Name of Family Physician

Specialist

Do you have any other disease, condition or problem not listed above that you think the doctor should know about?

Yes No

If yes, what?

Please list any and all medications taken, including prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins or minerals:

Are you allergic or have you had any adverse reaction to

Local Anesthesia (Novocain, etc..)

Codeine or other pain killers

Latex or Rubber products

Penicillin

Aspirin or Ibuprofen

Metal of any kind

Antibiotics

Others

Any allergies not listed above

Have you ever had any excessive bleeding requiring special treatment?

Yes No

If yes, for what reason?

Do you use or have you ever used recreational drugs?

Yes No

Do you smoke?

Yes No

Do you drink alcoholic beverages?

Yes No

If so, how often

Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect the care we provide you?

Yes No

When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest or shortness of breath or because you are very tired?

Yes No

Do your ankles swell during the day?

Yes No

Have you lost/gained more than 10 lbs. in last year?

Yes No

Do you use more than two pillows to sleep?

Yes No

Do you ever wake up from sleep short of breath

Yes No

Has your medical doctor ever said you have a cancer or tumor?

Yes No

Have you had any serious problems associated with any previous dental treatment?

Yes No

WOMEN – Are you pregnant or nursing or is there any chance you might be pregnant?

Yes No

If you are using oral contraceptives, it is important you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills after the course of antibiotics or other medication is completed. Please consult your physician for further guidance.

FOR ALL PATIENTS: I understand the importance of a truthful and complete Health History to assist my doctor in providing the best care possible. I have had the opportunity to discuss my Health History with my doctor. I hereby authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated in connection with the dental care of the patient above and further authorize and consent that the doctor chooses and employs such assistance as he deems fit. I also understand that previous to treatment full explanation of the procedure(s) involved will be given by the doctor and/or his staff. I agree to pay for all the services rendered by this office

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature (or Responsible Party, if minor)

Relationship

Date

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