www.titusdentistrymiddletown.com - Patient Medical History Form

Patient Medical History Form - Middletown
Patient Name*

First NameMiddle NameLast Name
Gender*
General Medical Information
I am currently under a physician's care
Physician type
Physician's Name
Physician's Phone Number
I have been hospitalized or have required a major operation*

YesNo
Please Explain *
I have been involved in a serious head or neck injury*

YesNo
Please Explain *
I am currently on a special diet*

YesNo
Please Explain *
I am or have taken Phen-Fen or Redux*

YesNo
Please Explain *
I use tobacco*

YesNo
Please describe the current amount and frequency as well as the length of use*
I use alcohol *

YesNo
Please describe the current amount and frequency as well as the length of use*
I use a controlled substance*

YesNo
Please describe the current amount and frequency as well as the length of use*
I required an antibiotic prior to dental appointments*

YesNo
Please tell us what antibiotic and dosage you take*
Please list any prescription or over the counter medications and herbal supplements you currently take.
Have you had any surgeries?*

YesNo
Please describe
Preferred Pharmacy
Allergies
AspirinPenicillinCodeineAcrylicMetalLatexOther
Please list
For Women
Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?
Medical Conditions
AID/HIVAlzheimerAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionCancerChemotherapyChest PainsCold SoresCongenial Heart DisorderConvulsionsCortisone MedicineCrohn's DiseaseDiabetesDiarrheaDrug AdditionEpilepsy/SeizuresExcessive BleedingExcessive ThirstEmphysemaHay FeverFrequent HeadachesGenital HerpesHigh Blood PressureHeart DiseaseHeart AttackHeart MurmurFrequent CoughHepatitis B or CHemophiliaHives or RashGlaucomaIrregular HeartbeatHerpesLeukemiaHeart PaceMakerPsychiatric DiseaseKidney ProbelmsShinglesHepatitis ARheumatismRadiationIntestine DiseaseHypoglycemiaSinus ProblemsScarlet FeverTonsilitisLiver DiseaseSwelling LimbsSpina BifidaYellow JaundiceRheumatic FeverStrokeThyroid DiseaseTuberculosisSickle CellVenereal DiseaseTumors or Growths
Please list any other illnesses you have had that are not listed above
Signature*

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Name of person completing this form*

First NameLast Name
Date*

MonthDayYear
Date
Please verify that you are human*
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Patient Medical History Form - Middletown

General Medical Information

Allergies

For Women

Medical Conditions