Dentistry On 66
Medical History Form
d066 Medical History Form
Name
Name
First
First
Last
Last
Address (Home)
Date
Emergency Contact
Relationship
Day-Time Phone
Home Phone
Name of Family Doctor
Occupation
The Following is required to enable us to provide you with the best possible dental care. All information is strictly private and protected by doctor-patient confidentiality. The dentist will review the question and explain any that you do not understand. Please fill in the entire form.
Are you being treated for any medical condition at the present or have been within the past year? If so, why?
Yes
Yes
No
When Was Your Last Medical Checkup
Have been any changes in your general health in the past year? If yes, please explain.
Yes
Yes
No
Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes. please list.
Yes
Yes
No
Do you have any allergies? If you answer yes. please list using the categories below:
Latex/Rubber Products
Latex/Rubber Products
Medications
Medications
Other (hay, fever, foods)
Other (hay, fever, foods)
Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes. please explain?
Yes
Yes
No
Do you have or have you ever had asthma?
Yes
No
Do you have high blood pressure?
Yes
No
Do you have or have you ever had a heart murmur. mitral valve prolapsed or rheumatic fever?
Yes
No
Do you have a prosthetic or artificial joint?
Yes
No
Have you ever been advised by your doctor to take antibiotics before dental treatment?
Yes
No
Do you have any conditions or therapies that could affect your immune system e.g., leukemia. AIDS, HIV, infection, radiotherapy, chemotherapy?
Yes
No
Have you ever had hepatitis, jaundice or liver disease?
Yes
No
Do you have bleeding problem or bleeding disorder?
Yes
No
Have you ever been hospitalized for any illness or operation? If yes. please explain?
Yes
Yes
No
Have you ever been hospitalized for any illness or operation? If yes, please check.
chest pain
steriod therpay
pacemaker seizures(epilepsy)
stroke
drug/alcohol
dependency heart attack prosthetic heart lung disease
tuberculosis
cancer
diabetes stomach ulcers arthritis
kidney disease thyroid disease angina
shortness of breath
kidney disease
thyroid disease
arthritis
stomach ulcers
Are there any conditions or disease not listed above that you have or had? If so, what?
Yes
Yes
No
Are there any diseases or medical problems that run in your family? E.g., diabetes, cancer or heart disease.
Yes
Yes
No
Do you smoke or chew tobacco products?
Yes
No
Are you nervous during dental treatment?
Yes
No
Are you breast feeding or pregnant? If pregnant, what is expected delivery?
Yes
Yes
No
To the best of my knowledge, the above information is correct: PLEASE BE AWARE WE DO REQUIRE 48 HOURS (2 BUSINESS DAYS) NOTICE FOR ANY CANCELLATIONS IN ORDER TO AVOID A CANCELLATION FEE. THANK YOU
Patient Signature
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Date
Doctor Signature
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Date
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