Medical History Form

Medical History
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Are you currently taking any medications? Please specify*
Do you have any allergies to medications? Please specify*
Do you have a latex allergy?*

YesNo
Do you have any allergies to dental materials? Please specify*
Are you under the care of a physician for any medical conditions? Please specify*
Have you had your tonsils and/or adenoids removed?*

NoTonsilsAdenoidsTonsils and Adenoids
Please list any surgeries you have had:*
Do you currently use any form of nicotine?*
Please check if you have had or currently have any of the following conditions:*

I do not have any of the below conditionsAIDS/HIVAnemiaAsthmaBone DisorderBlood DiseaseBronchitisCancerDevelopmental DisorderDiabetesDizziness or FaintingEmotional ProblemsEndocrine DisorderEpilepyFacial/Jaw/TMJ PainFrequent HeadachesGrowth DisordersHeart ConditionHeart MurmurHearing ImpairedHepatitisHernia RepairHerpes/Cold SoresHives/RashKidney DisorderLiver DisorderMouth BreatherMitral Valve ProlapseNervous/AnxiousProne to coldsProne to ear infectionsProne to sore throatsProlonged BleedingPsychiatric CareRheumatic FeverTonsilitisTrauma to face or JawTuberculosisUlcerVertigoVision Impaired (partial or complete blindness)
Signature*

Clear
Date*
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