Medical History Medical History Patient Name * Date of Birth * Date Created Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? * Yes No Please supply details: * Have you ever been hospitalized or had a major operation? * Yes No Please supply details: * Have you ever had a serious head or neck injury? * Yes No Please supply details: * Are you taking any medications, pills or drugs? * Yes No Please supply details: * Have you had Botox, Dermal filters or other facial cosmetic procedures? * Yes No Date of procedure * Please supply details: * Are you on a special diet? * Yes No Do you use tobacco? * Yes No Type of tobacco used * Do you use controlled substances? * Yes No Please supply details: * Women: Are you... Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives? Are you allergic to any of the following? Aspirin Metal Penicillin Latex Codeine Sulfa Drugs Acrylic Local Anesthetics OtherOther Do you have or have you had any of the following? AIDS/HIV Positive * Yes No Cortisone Medicine * Yes No Hemophilia * Yes No Radiation Treatments * Yes No Alzheimer's Disease * Yes No Diabetes * Yes No Hepatitis A * Yes No Recent Weight Loss * Yes No Anaphylaxis * Yes No Drug Addiction * Yes No Hepatitis B or C * Yes No Renal Dialysis * Yes No Anemia * Yes No Easily Winded * Yes No Herpes * Yes No Rheumatic Fever * Yes No Angina * Yes No Emphysema * Yes No High Blood Pressure * Yes No Rheumatism * Yes No Arthritis/Gout * Yes No Epilepsy or Seizures * Yes No High Cholesterol * Yes No Scarlet Fever * Yes No Artificial Heart Valve * Yes No Excessive Bleeding * Yes No Hives or Rash * Yes No Shingles * Yes No Artificial Joint * Yes No Excessive Thirst * Yes No Hypoglycemia * Yes No Sickle Cell Disease * Yes No Asthma * Yes No Fainting Spells/Dizziness * Yes No Irregular Heartbeat * Yes No Sinus Trouble * Yes No Blood Disease * Yes No Frequent Cough * Yes No Kidney Problems * Yes No Spina Bifida * Yes No Blood Transfusion * Yes No Frequent Diarrhea * Yes No Leukemia * Yes No Stomach/Intestinal Disease * Yes No Breathing Problems * Yes No Frequent Headaches * Yes No Liver Disease * Yes No Stroke * Yes No Bruise Easily * Yes No Genital Herpes * Yes No Low Blood Pressure * Yes No Swelling of Limbs * Yes No Cancer * Yes No Glaucoma * Yes No Lung Disease * Yes No Thyroid Disease * Yes No Chemotherapy * Yes No Hay Fever * Yes No Mitral Valve Prolapse * Yes No Tonsillitis * Yes No Chest Pains * Yes No Heart Attack.Failure * Yes No Osteoporosis * Yes No Tuberculosis * Yes No Cold Sores/Fever Blisters * Yes No Heart Murmur * Yes No Pain in Jaw Joints * Yes No Tumors or Growths * Yes No Congenital Heart Disorder * Yes No Heart Pacemaker * Yes No Parathyroid Disoirder * Yes No Ulcers * Yes No Convulsions * Yes No Heart Trouble/Disease * Yes No Psychiatric Care * Yes No Venereal Disease * Yes No Yellow Jaundice * Yes No Eating Disorder * Yes No Acid Reflux * Yes No Have you ever had any serious illness not listed? * Yes No Please provide details: * Comments To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical treatment. Signature * Clear Today's Date Submit