Patient Medical History Form

Please correct the errors described below.

Patient Name:

Do you or have you had any of the following:

Blood pressure:

High Low None

Heart Attack:

Yes No

If Yes, When?

Cardiac Pacemaker:

Yes No

Chest Pains/Angina:

Yes No

Heart Murmur:

Yes No

Heart Disease

Yes No

Stroke

Yes No

Fainting Spells, Seizures, or Convulsions:

Yes No

Rheumatic Fever:

Yes No

Asthma:

Yes No

Emphysema:

Yes No

Easily Winded:

Yes No

Tuberculosis:

Yes No

Respiratory Problems:

Yes No

Liver Disease:

Yes No

Hepatitis or Jaundice:

Yes No

Kidney Diseases:

Yes No

Leukemia:

Yes No

Diabetes:

Yes No

Thyroid Problems:

Yes No

Radiation Treatment

Yes No

AIDS or HIV Infection:

Yes No

Cancer

Yes No

If Yes, What type?

Sexually Transmitted Disease:

Yes No

Anemia

Yes No

Stomach Ulcers:

Yes No

Recent Weight Loss:

Yes No

Glaucoma:

Yes No

Have You Ever Taken Fen-Phen or Redux?

Yes No

Have You Ever Taken A Bisphosphonate, Such As Boniva or Fosamax?

Yes No

Do You Have Any Artificial Joints?

Yes No

Are You Pregnant Or Nursing?

Yes No

Do You Use Tobacco Products?

Yes No

If yes, # of Packs Per Week

Do You Use?

Alcohol

Cocaine

Other Recreational Drugs

Are You Currently Under Medical Treatment?

Yes No

for?

Have You Been Hospitalized In The Last Year?

Yes No

for?

Are You Allergic To Any Medications, Dyes, or Latex?

Yes No

for?

Please List Any Medications You Are Taking, Including Non-Prescription Supplements:

What Brings You In To See Us Today?

Approximately When Was The Last Time You Saw A Dentist?

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