Patient Dental & Medical Health
Check ALL that apply
Do you have or had
Cancer or tumor
Heart ailment or angina
Heart murmur, defect, mitral valve prolapse
Rheumatic fever or rheumatic heart disease
Artificial joint or valve
High or low blood pressure
Pacemaker
Tuberculosis or other lung problems
Kidney disease
Hepatitis or other liver disease
Alcoholism
Blood transfusion
Diabetes
Neurologic condition
Epilepsy, seizures, or fainting spells
Emotional condition
Arthritis
Herpes or cold sores
AIDS or HIV positive
Migraine headaches or frequent headaches
Anemia or blood disorders
Abnormal bleeding after extractions, surgery, or trauma
Hayfever or sinus trouble
Allergies or hives
Asthma
Are you allergic to, or have reacted adversely to:
Latex materials
Penicillin or other antibiotics
Local anesthetics (“Novocain”)
Codeine or other narcotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin
Other
Are you taking any of the following?
Aspirin
Anticoagulants (blood thinners)
Antibiotics or sulfa drugs
High blood pressure medicine
Antidepressants or tranquilizers
Insulin, Orinase, or other diabetes drug
Nitroglycerinq Cortisone or other steroids
Osteoporosis (bone density) medicine
Other
Women
May be pregnant
Taking hormones or contraceptives
Nursing
Do you smoke or use chewing tobacco?
Y
N
Your Physician Name
First Name
Last Name
Date of Last Visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any disease, condition, or problem not listed above?
Is there anything else you would like us to know about?
Signature of patient/guardian:
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