Patient Medical History

Medical History

Physician Name:

Office Address:

Telephone #

Are you currently under the care of a physician?

Yes No

Explain

Has there been a recent change in your health?

Yes No

Explain

Are you currently taking any prescription, over the counter or recreational drugs?

Yes No

Please List

Have you been hospitalized or had a serious illness within the past five years?

Yes No

Explain

Have you been treated now or in past with Bisphosphonates for Osteoporosis or cancer?

Yes No

Explain

Are you pregnant or is it likely that you could be pregnant at this time?

Yes No

If so, how far along?

Do you take blood thinners?

Yes No

If so, Type:

Do you smoke?

Yes No

Packs per day?

How long?

Do you chew Tobacco

Yes No

Select Yes/No if you have or ever had:

Artificial Limb/Joint/Hip

Yes No

When?

Artificial Heart Valve

Yes No

Acid Reflux

Yes No

Arthritis

Yes No

Anemia

Yes No

Asthma

Yes No

Angina

Yes No

Addictions

Yes No

Type:

Blood Disorder

Yes No

Type:

Aspirin Daily

Yes No

Bells Palsy

Yes No

Cancer

Yes No

Type:

Chronic Diarrhea

Yes No

Dizziness/Fainting

Yes No

Diabetes

Yes No

Type:

Type I Type II

Epilepsy/Seizures

Yes No

Emphysema

Yes No

Frequent Urination

Yes No

Glaucoma

Yes No

High Blood Pressure

Yes No

Hay Fever

Yes No

Head Injury

Yes No

Heart Murmur

Yes No

High Cholesterol

Yes No

Hyperthyroidism

Yes No

Hypothyroidism

Yes No

Hepatitis:

A B C

Heart Disease

Yes No

Explain:

Joint Surgery

Yes No

Kidney Problems

Yes No

Low Blood Pressure

Yes No

Migraines

Yes No

Mitral Valve Prolapse

Yes No

Mouth Ulcers

Yes No

Organ Transplant

Yes No

Prolonged Bleeding

Yes No

Psychiatric Care

Yes No

Pacemaker

Yes No

Rheumatic Fever

Yes No

Radiation Therapy

Yes No

Recurrent Infections

Yes No

Sinus Problems

Yes No

Stroke / TIA

Yes No

Date

STD

Yes No

Type:

Shortness of Breath

Yes No

Treated for AIDS/HIV

Yes No

Tuberculosis

Yes No

Trigeminal Neuralgia

Yes No

Ulcers/Colitis

Yes No

Unexplained Weight Loss

Yes No

If Other, please specifiy:

I authorize the doctor to perform all recommended treatment agreed upon by me and to use the appropriate medication and therapy for such treatment in connection with [Enter Patient Name below]. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and give consent to the doctor to use and employ such assistance as deemed to provide recommended treatment.

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

Patient or Responsible Party Signature

Date

Dentist Signature

Date

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