Medical History Form

Leon J. Leonard, D.M.D.

Please correct the errors described below.

Patient's Name

Date of Birth

MEDICAL HISTORY

Are you in good health?

History of Major Illness

Are you presently under the care of a physician for a specific problem?

If so, Please explain

PLEASE CHECK THE FOLLOWING AS THEY APPLY

Contact Lenses

Glaucoma

Heart Trouble

Kidney Disease

Hepatitis/Liver Disease

High Blood Pressure

Allergies or Asthma

Rheumatic Fever

Venereal Disease

Epilepsy

Bleeding Problems

Diabetes

Jaw Joint Pain (TMJ)

Arthritis

Facial Injury

Bone Disorders

Endocrine Problems

Night Grinding of Teeth

Emotional Problems

List Any Medicines Now Being Taken. Give Reasons

List Any Allergies or Drug Sensitivities

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Signature of Parent or Guardian

Date

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