Medical History Form

Patient's Name

Nickname

Age

Name of Physician/and their specialty

Most recent physical examination

Purpose

What is your estimate of your general health?

Excellent

Good

Fair

Poor

DO YOU HAVE or HAVE YOU EVER HAD

ARE YOU

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List all medications, supplements, vitamins, and/or probiotics taken within the last two years.

Add new row

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Patient's Signature

Date

Patient's Signature

Date

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