Medical History Questionnaire

Patient's Name

Age

Date

Occupation (if retired, past occupation)

If you had any serious illness, operation, or hospitalization, please explain:

If YES, what is the drug name and how is it administered (please circle)?

Oral

Injectable

Intra-Venous

Please list all prescription and over-the-counter medication and the conditions for which you are taking them in the space provided:

Add new row

Your Pharmacy Name

Telephone No.

ALLERGIES

For Medication, If yes, Please list

Do you currently or have you ever had any of the following medical conditions?

If other, please specify

Physician's Name

Date of last physicial exam

Phone No.

To the best of my knowledge, the above information is complete and accurate.

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's Signature

Date

Signature of Parent or Guardian (If the patient is a minor)

Information about the tooth / teeth to be evaluated today:

Worse at certain times of the day?

When?

Radiating to

What makes the pain better?

How long have you been in pain?

Condition of the tooth

Decay

Broken (missing a piece or filling)

Cracked

Recent dental work done on the tooth / teeth?

What?

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