Medical History  Form                                             Date

Name                                                                         Home  Phone (                               )

Address  ‑                                                                    Business Phone (                         )

City                                                          State                                 Zip Code

Occupation                                                                               Social  Security No.

Date of Birth                           Sex M F            Height            Weight              Single_______ Married_______

Name of Spouse                             Closest  Relative                  Phone (                                  )

If you are completing this form for another person, what is your relationship to that person?

Referred by

For  the following questions, circle yes or no, whichever applies. Your answers  are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

1. Are you in good health? . . . . . .	Yes	No
2. Has there been any change in your general health within the past year?	Yes	No
3. My last physical examination was on
4. Are you now under the care of a physician?	Yes	No
If so, what is the condition being treated?
5. The name  and address of my physician(s) is:
6. Have  you had any serious illness, operation, or been hospitalized in the past 5 years?	Yes	No
If so, what was the illness or problem?
7. Are you taking any medicine(s) including non‑prescription medicine?	Yes	No
If so, what medicine(s) are you taking?
8. Do you have or have you had any of the following diseases or problems?
a. Damaged heart valves or artificial heart valves, including heart murmur  or rheumatic heart disease	Yes	No
b. Cardiovascular disease (heart trouble, heart attack, angina, coronary  insufficiency, coronary occlusion, high bloodpressure, arteriosclerosis, stroke)	Yes	No
1. Do you have chest pain upon exertion?	Yes	No
2. Are you ever short of breath after mild exercise or when lying down?	Yes	No
3. Do your ankles swell?	Yes	No
4. Do you have inborn heart defects?	Yes	No
5. Do you have a cardiac pacemaker?	Yes	No
Do you have?
c. Allergy	Yes	No
d. Sinus trouble	Yes	No
e. Asthma or hay fever	Yes	No
f. Fainting spells or seizures	Yes	No
g. Persistent diarrhea or recent weight loss	Yes	NO
h. Diabetes	Yes	No
i. Hepatitis, jaundice or liver disease	Yes	No
j. AIDS or HIV infection	Yes	No
k. Thyroid problems	Yes	No
L. Respiratory problems, emphysema, bronchitis, etc	Yes	No
m. Arthritis or painful swollen joints	Yes	No
n. Stomach ulcer or hyperacidity	Yes	No
o. Kidney trouble	Yes	No
p. Tuberculosis	Yes	No
q. Persistent cough or cough that produces blood	Yes	No
r. Persistent swollen glands in neck	Yes	No
s. Low blood pressure	Yes	No
t. Sexually transmitted disease	Yes	No
u. Epilepsy or other neurological disease	Yes	No
v. Problems with mental health	Yes	No
w. Cancer	Yes	No
x. Problems of the immune system	Yes	No
9. Have you had abnormal bleeding?	Yes	No
a. Have you ever required a blood transfusion?	Yes	No
10.  Do you have any blood disorder such as anemia?	Yes	No
11.  Have you ever had any treatment for a tumor or growth?	Yes	No
12. Are you allergic or have you had a reaction to:	Yes	No
a. Local anesthetics	Yes	No
b. Penicillin or other antibiotics	Yes	No
c. Sulfa drugs	Yes	No
d. Barbiturates, sedatives, or sleeping pills	Yes	No
e. Aspirin	Yes	No
f. Iodine	Yes	No
g. Codeine or other narcotics	Yes	No
h. Other	Yes	No
13.  Have you had any serious trouble associated with any previous dental  treatment?	Yes	No
If so, explain ‑  ‑
14.  Do you have any disease, condition, or problem not listed above that  you think I should know about?	Yes	No
If so, explain ‑.
15.  Are you wearing contact lenses?	Yes	No
16.  Are you wearing removable dental appliances?	Yes	No
Women
17.  Are you pregnant?	Yes	No
18.  Do you have any problems associated with your menstrual period?	Yes	No
19.  Are you nursing?	Yes	No
20.  Are you taking birth control pills?	Yes	No
Chief dental complaint:
I certify  that I have read and understand the above. I acknowledge that my ques­tions,  if any, about the inquiries set forth above have been answered to  my satis­faction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. ____________________________________ Patient Signature

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