Patient Medical History Form Patient Name Last Name First Name Middle Name Contact Information Email Phone (Cell) Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your body. Health problems you may have, or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions: I am under a physician's care nowI have been hospitalized or have required a major operationI have been involved in a serious head or neck injuryI am currently taking medications, pills & drugsI am or have taken Phen-Fen or ReduxI am currently on a special dietI use tobaccoI use a controlled substanceI required a Premed Please Explain Women: Are you currently: PregnantTrying to get pregnant?Nursing?Taking oral contraceptives? Name and address of Pharmacy to call your prescription if needed Are you allergic to any of the following? AspirinPenicillinCodeineAcrylicMetalLatexOther Please Explain Do you have or had any of the following? AID/HIVAlzheimerAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionCancerChemotherapyChest PainsCold SoresCongenial Heart DisorderConvulsionsCortisone MedicineCrohn's DiseaseDiabetesDiarrheaDrug AdditionEpilepsy/SeizuresExcessive BleedingExcessive ThirstEmphysemaHay FeverFrequent HeadachesGenital HerpesFrequent CoughHeart DiseaseHeart AttackHeart MurmurGlaucomaHepatitis B or CHemophiliaHives or RashHeart PaceMakerIrregular HeartbeatHerpesLeukemiaHepatitis APsychiatric DiseaseKidney ProbelmsShinglesHypoglycemiaRheumatismRadiationIntestine DiseaseLiver DiseaseSinus ProblemsScarlet FeverTonsilitisRheumatic FeverSwelling LimbsSpina BifidaYellow JaundiceSickle CellStrokeThyroid DiseaseTuberculosisTumors or GrowthsVenereal Disease Have you ever had any serious illness not listed above? Explain I have read and agree to the Terms of Use
