Medical History

Patient's Name

Date of Birth

Email address

Medical Physician's Name

Type of Physician

How long

Physician's City/State

Physician's Phone #

DO YOU HAVE OR HAVE YOU EVER HAD

1. Hospitalization for illness or surgery in the last 5 years

Yes No

2. An allergic reaction

Yes No

3. Any reaction to:

a. aspirin

Yes No

b. penicillin

Yes No

c. erythromycin

Yes No

d. tetracycline

Yes No

e. codeine

Yes No

f. sedatives or sleeping pills (barbiturates)

Yes No

g. dental anesthetics

Yes No

h. latex

Yes No

i. other

Yes No

4. Hepatitis

Yes No

5. Jaundice (yellow skin on eyes)

Yes No

6. Epilepsy

Yes No

7. Arthritis

Yes No

8. Sexually Transmitted Disease

Yes No

9. Rheumatic Fever

Yes No

10. Scarlet Fever

Yes No

11. Anemia or other blood disorder

Yes No

12. Prolonged bleeding due to a slight cut

Yes No

13. Kidney Disease

Yes No

14. Diabetes

Yes No

15. Stomach disorder or acid reflux

Yes No

16. Liver Disease

Yes No

17. Tubercolosis

Yes No

18. Emphysema

Yes No

19. Thyroid or parathyroid disorders

Yes No

20. Heart condition

Yes No

21. Heart murmur

Yes No

22. A Pacemaker/Defibrillator

Yes No

23. Arteriosclerosis

Yes No

24. High Blood Pressure

Yes No

25. Low Blood Pressure

Yes No

26. An artificial heart valve or joint placed. Have you discussed with your physician the need for pre-medicating?

Yes No

27. A stroke

Yes No

28. Shortness of breath on mild exertion

Yes No

29. Chest pain on mild exertion

Yes No

30. Hives, skin rash, hay fever

Yes No

31. Asthma

Yes No

32. Psychiatric treatment

Yes No

33. A tumor or abnormal growth

Yes No

34. Radiation treatment by cobalt, radium, x-ray etc.

Yes No

35. Glaucoma

Yes No

36. Dry Mouth

Yes No

37. Prostate disorders (if male)

Yes No

38. AIDS (Acquired Immune Deficiency Syndrome)

Yes No

39. AIDS related diseases

Yes No

40. Blood transfusion

Yes No

41. Cosmetic lip or facial fillers

Yes No

42. Herpes

Yes No

43. Recreational Drugs

Yes No

44. History of drug or alcohol abuse

Yes No

45. HPV Gardasil vaccine

Yes No

ARE YOU:

1. Presently being treated for any illness

Yes No

2. Now taking any medication (please list below)

Yes No

3. Aware of a change in your general health

Yes No

4. Often exhausted or fatigued

Yes No

5. Subject to frequent headaches

Yes No

6. Smoker, or using any tobacco products

Yes No

7. Generally a nervous person

Yes No

8. Often unhappy and depressed

Yes No

9. Taking any naturopathic meds or supplements

Yes No

10. Using a C-Pap Device

Yes No

IF FEMALE, ARE YOU NOW:

1. Pregnant or nursing

Yes No

2. Taking birth control pills or other hormones

Yes No

3. Presently in menopause

Yes No

4. Past menopause

Yes No

PLEASE EXPLAIN FULLY ANY "YES" ANSWERS ABOVE

LIST ALL MEDICATION

IF THERE ARE ANY CHANGES IN MY MEDICAL HISTORY, I WILL NOTIFY THE DENTIST.

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

Today's Date

Your information will be encrypted.