Dental Care Center

Medical History

Please correct the errors described below.

Patient Information

First Name:

Middle Initial:

Last Name:

Medical History

Have you ever had any serious illnesses or operations?

If yes, describe:

Physician:

Date of last visit:

Medications

List of medications

Allergies

List of allergies

(Women) Are you pregnant?

Yes No

Nursing?

Yes No

Taking birth control pills?

Yes No

Do you have a history of any of the following? (please check all that apply)

Pacemaker

Heart Condition

Artificial Heart Valves

Heart Murmur

MVP

H/L Blood Pressure

Shortness of Breath

Respiratory/Asthma

Rheumatic Fever

Jaundince/Liver

Thyroid/Hormonal

Hepatitis

Sinusitis

Tuberculosis

Radiation/Chemo

Cancer

Arthritis-Rheumatoid/Osteopenia

Ulcers/Digestive

Glaucoma/Visual

Mental/Neural

Stroke/Clotting disorder

Dementia/Alzheimer's

Migraines/Headaches

Epilepsy/Fainting

Immunocompromised

Joint Replacement

Tobacco Habit

Anemia/Bleeding

Respiratory Disease

Circulatory Problems

Diabetes/Kidney

Tumor/Neoplasms

Alcoholism/Addiction

Infectious Diseases

Venereal Disease

HIV/AIDS

Herpes

Back Problems

Person to contact in case of emergency:

Phone #:

I have read my MEDICAL HISTORY and confirm that it adequately states past and present conditions.

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

Signature:

Date:

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