Medical History Form

Please correct the errors described below.

Name

Current health is:

Good Fair Poor

Are you currently under the care of a physician?

Yes No

If yes, why?

List any known allergies you have:

Are you pregnant?

Yes No

How many weeks?

Have you ever been diagnosed with a disease or condition?

Yes No

If yes, please check all that apply.

Blood disorder

Radiation/chemotherapy

Fainting spells

Anemia

Hepatitis type

Alcohol/drug abuse

Scarlet Fever

Smoker/tobacco use

Low or High blood pressure

Artificial/bones/joints

Heart murmur

Heart Attack/Heart surgery

Artificial valve replacement

Mitral Valve Prolapse

Stroke

Liver Disease

Diabetes

Seizures

Tuberculosis

Pacemaker

Mental Health

Other:

Have you ever required pre-medication with antibiotics prior to dental treatment before?

Yes No

If yes, please explain:

List any medications you are currently taking or provide a list:

Dental History

How long since your last dental visit?

What would you like to do to improve your smile?

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/Guardian’s signature

Date

Your information will be encrypted.

DeVito Dental Solutions

(304) 292-1764
1300 University Avenue , Morgantown, WV, 26505

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