www.titusdentistrymiddletown.com - Patient Medical History Form

Patient Medical History Form - Middletown
Patient Name *

First Name Middle Name Last Name
Gender *
General Medical Information
I am currently under a physician's care
Physician type
Physician's Name
Physician's Phone Number
I have been hospitalized or have required a major operation *

Yes No
Please Explain *
I have been involved in a serious head or neck injury *

Yes No
Please Explain *
I am currently on a special diet *

Yes No
Please Explain *
I am or have taken Phen-Fen or Redux *

Yes No
Please Explain *
I use tobacco *

Yes No
Please describe the current amount and frequency as well as the length of use *
I use alcohol *

Yes No
Please describe the current amount and frequency as well as the length of use *
I use a controlled substance *

Yes No
Please describe the current amount and frequency as well as the length of use *
I required an antibiotic prior to dental appointments *

Yes No
Please tell us what antibiotic and dosage you take *
Please list any prescription or over the counter medications and herbal supplements you currently take.
Have you had any surgeries? *

Yes No
Please describe
Allergies
Aspirin Penicillin Codeine Acrylic Metal Latex Other
Please list
For Women
Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?
Medical Conditions
AID/HIV Alzheimer Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Cancer Chemotherapy Chest Pains Cold Sores Congenial Heart Disorder Convulsions Cortisone Medicine Crohn's Disease Diabetes Diarrhea Drug Addition Epilepsy/Seizures Excessive Bleeding Excessive Thirst Emphysema Hay Fever Frequent Headaches Genital Herpes High Blood Pressure Heart Disease Heart Attack Heart Murmur Frequent Cough Hepatitis B or C Hemophilia Hives or Rash Glaucoma Irregular Heartbeat Herpes Leukemia Heart PaceMaker Psychiatric Disease Kidney Probelms Shingles Hepatitis A Rheumatism Radiation Intestine Disease Hypoglycemia Sinus Problems Scarlet Fever Tonsilitis Liver Disease Swelling Limbs Spina Bifida Yellow Jaundice Rheumatic Fever Stroke Thyroid Disease Tuberculosis Sickle Cell Venereal Disease Tumors or Growths
Please list any other illnesses you have had that are not listed above
Signature *

Clear
Name of person completing this form *

First Name Last Name
Date *

Month Day Year
Date
Please verify that you are human *
Should be Empty:

Patient Medical History Form - Middletown

General Medical Information

Allergies

For Women

Medical Conditions