Medical History
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
What is your Gender?
*
Male
Female
Is your general health good?
*
Yes
No
If No, explain:
*
Has there been a change in your health within the last year?
*
Yes
No
If Yes, explain:
*
Have you gone to the hospital/emergency room or had a serious illness in the last three years?
*
Yes
No
If Yes, explain:
*
Are you being treated by a physician now?
*
Yes
No
If Yes, explain:
*
Date of last medical exam?
-
Month
-
Day
Year
Date
What is this exam for?
Check the followings that you have had or currently have:
*
High blood pressure
Heart disease
Heart Murmurs
Heart defects
Artificial heart valve/heart transplant
Hardening of arteries
Heart attack
Stroke
Joint replacement
Osteoporosis
Anemia/blood disorder
Arthritis, rheumatism
Rheumatic fever
Diabetes
Thyroid disease
Liver disease
Hepatitis
Kidney or bladder disease
Asthma
Emphysema or other lung disease
Skin disease
Stomach problems or ulcers
Seizures
AIDS/HIV
Sexual transmitted disease
Herpes
Tumors/cancer
Chemotherapy/radiation
Eating disorders
Transplant
No Conditions
Other
Check the medications/substances that you are allergic to or have had a reaction to:
*
Aspirin (Aleve)
Ibuprofen (Advil/Motrin)
Tylenol (Acetaminophen)
Penicillin or other antibiotics
Nitrous oxide
Codeine or other opioids
Local anesthetic
Latex
Metal
Food (Please specify under Other)
No Allergies
Other
Are you currently taking any medication?
*
Yes
No
Please list the medications, dietary or herbal supplements you are currently taking and their dosages: (Put "None" or "N/A" if you are not taking any medications or supplements)
*
Are you currently taking bisphosphonates?
*
Yes
No
Do you use or do you have history of using tobacco?
*
Yes
No
Do you use or do you have history of using recreational drugs?
*
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Are you nursing?
*
Yes
No
Are you Pregnant?
*
Yes
No
Do you have or have you had any other diseases or medical problems not listed on this form?
*
Yes
No
If Yes, please explain
*
Do you need antibiotic prophylaxis for dental treatment?
*
Yes
No
Patient's Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Doctor's Signature
Office's Email
example@example.com
Should be Empty: