Medical History

Name:

E‐mail:

Phone:

Are you in good health?

Yes No

Height:

Weight:

Has there been any change in your general health?

Yes No

Your last physical examination was on:

Are you now under the care of a physician?

Yes No

Name of your physician:

Address of your physician:

Have you ever had a serious illness or operation?

Yes No

Have you been hospitalized with any of the following within the last 5 years?

Do you have a persistent cough or cough up blood?

Yes No

Low/High blood pressure(circle one)

Yes No

Venereal Disease

Yes No

AIDS or HIV+

Yes No

Other:

Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?

Yes No

Do you bruise easily?

Yes No

Have you ever required a blood transfusion

Yes No

If yes, explain the circumstances:

Do you have any blood disorder such as anemia?

Yes No

Have you had surgery or x‐ray treatment for a tumor, growth or other condition of your mouth or lips?

Yes No

Are you taking any drug or medication?

Yes No

If yes, what?

Do you smoke?

Yes No

If yes, how much?

Do you drink alcoholic beverages?

Yes No

Do you take any recreational drugs?

Yes No

Cardiac pacemaker

Yes No

A removable dental appliance

Yes No

Implants/Artificial prosthesis (Knee joints, elbow pins etc)

Yes No

Rheumatic fever or rheumatic heart disease

Yes No

Hepatitis, jaundice, or liver disease

Yes No

Heart Murmur or mitral valve prolapse

Yes No

Congenital heart lesions

Yes No

Convulsions/epilepsy

Yes No

Stroke

Yes No

Asthma or hay fever

Yes No

Hives or skin rash

Yes No

Fainting spells or seizures

Yes No

Arthritis

Yes No

Inflammatory rheumatism (painful, swollen joints)

Yes No

Stomach ulcers

Yes No

Kidney trouble

Yes No

Tuberculosis

Yes No

A tumor or growth

Yes No

Radiation therapy or chemotherapy

Yes No

Thyroid trouble

Yes No

Bleeding tendency /abnormal bleeding

Yes No

Are you immunosuppressed? Possibly from transplant surgery

Yes No

Cardiovascular disease (heart trouble, heart attack, coronary occlusion, high blood pressure, arteriosclerosis, stroke)

Yes No

Do you have pain in the chest upon exertion?

Yes No

Are you ever short of breath after mild exercise?

Yes No

Do you get short of breath when you lie down or do you require extra pillows when you sleep?

Yes No

Diabetes

Yes No

Do you have to urinate (pass water) more than six (6) times a day?

Yes No

Are you thirsty much of the time?

Yes No

Does your mouth frequently become dry?

Yes No

Have you had any serious trouble associated with previous dental treatment?

Yes No

If yes, explain:

Are you pregnant or could you be?

Yes No

If yes, when are you due?

Are you nursing?

Yes No

Are you taking oral contraceptives?

Yes No

If yes, what?

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Date:

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Name:

Date:

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Name:

Date:

Medical History

Medications

Habits

Do you have any of the following?

Do you have, or have you had, any of the following diseases or problems?

Allergy

For Women Only

Patient's Signature:

Guardian's Signature:

Doctor's Signature: