MEDICAL HISTORY Patient Name Birth Date DENTAL HISTORY What is your reason for today’s visit? When was your last visit to a dentist? Have your past dental experiences been satisfactory? How do you feel about the appearance of your teeth? MEDICAL HISTORYDo you have or have you had any of the following? (Please check all that apply to you) Aids/HIVAlzheimer’s/DementiaAnemiaAnginaArtificial heart valveArthritisAsthmaAutoimmune disordersBlood disordersChemotherapyCongenital Heart DefectsEpilepsyGlaucomaHead/Neck InjuriesHearing AidsHeart Disease/AttackHeart MurmurHeart PacemakerHepatitis A/B/CHerpesHigh/Low Blood PressureMedical MarijunaKidney DiseaseMental/Psychiatric DisorderMitral Valve ProlapseOrgan TransplantRheumatic FeverShinglesSinus TroubleSmoker (nicotine, canibus, etc)Stomach ProblemsStrokeOther Artificial Joints Diabetes/Type Cancer (Yr) Osteoporosis (Yr Diagnosis) If yes to any of the above please explain Physician Tel# Date of last physical exam Please list all medications as well as any over the counter medication, vitamins or Herbal or Homeopathic remedies Are you currently under a physician’s care? Explain Do you take aspirin daily? Do you Require Antibiotic Pre-Medication? Allergies/Reactions to Medications, or other allergies? (Latex or food?) (Women) Are you Pregnant? Nursing? Taking Birth Control? Do you suffer from Dental Anxiety? If so please rate your anxiety from 1-10 To the best of my knowledge, the questions on this form have been accurately answered. I understand providing incorrect Information can be dangerous to my health. It is my responsibility to inform the dental office of any changes to my health. [anr_nocaptcha g-recaptcha-response]
