Medical History Form

Medical History

Tao Dental Care - www.dentaltao.com, 10011 N. Foothill Blvd #109, Cupertino, CA 95014, yuan.tao.dmd@gmail.com, (408) 737-2988
Patient Name

Last NameFirst NameMiddle Name
Preferred Name
Phone Number*

Area CodePhone Number
Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO"response

*Pre-Med - AmoxAllergy - AspirinAllergy - LatexAnemiaBlood DiseaseDizzinessGlaucomaHepatitisKidney DiseaseOsteoporosis MedsRadiation TreatmentSinus ProblemsThyroid Disease*Pre-Med - ClindAllergy - CodeineAllergy - OtherArthritisBlood ThinnerEpilepsyHead InjuriesHigh Blood PressureLiver DiseaseRespiratory ProblemsSTDTuberculosis*Pre-Med - OtherAllergy - ErythroAllergy - PenicillinArtificial JointsCancerExcessive BleedingHeart DiseaseHIVMental DisordersPacemakerRheumatic FeverStomach ProblemsTumorsAllergiesAllergy - Hay FeverAllergy - SulfaAsthmaDiabetesFaintingHeart MurmurJaundiceNervous DisordersPregnancyRheumatismStrokeUlcers
Ever been hospitalized (illness or injury)Presently being treated for any other illnessesSubject to frequent headaches(illness or injury) Presently being treated for any other illnesses Subject to frequent headachesTFEMALE: Taking birth control pillsFEMALE: Pregnant
If any conditions or alerts selected above need further clarification, please describe below:
Do you take antibiotic premedication for your dental visits? If yes, please explain.
What is your estimate of your general health?

ExcellentGoodFairPoor
Name of your physician and phone number:
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment
List all medications (prescription and non-prescription) including regular doses of aspirin:
By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly.There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practiceof any future changes. This will serve as my electronic signature.*

Check this box
Response Date

MonthDayYear
Date
Should be Empty: