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English (US)
MEDICAL HEALTH HISTORY
Patient's Name
*
Date of Birth
*
/
Month
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Day
Year
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Do you have any of the following? Check all that apply.
Abnormal bleeding after extractions, surgery, or trauma
AIDS or HIV Positive
Alcoholism
Allergies or hives
Anemia or blood disorders o Arthritis
Artificial joint or valve
Asthma
Blood transfusion
Cancer or tumor
Diabetes
Emotional condition
Epilepsy, seizures, or fainting spells o Hay fever or sinus trouble
Heart ailment or angina
Heart murmur, mitral valve prolapse, heart defect
Hepatitis or other liver disease
Herpes or cold sores
High or low blood pressure
Kidney disease
Migraine headaches or frequent headaches
Neurologic condition
Pacemaker
Rheumatic fever or rheumatic heart disease
Tuberculosis or other lung problems
Do you smoke or use chewing tobacco?
Yes
No
Are you allergic to, or have you reacted adversely to any of the following? Check all that apply.
Aspirin
Barbiturates, sedatives, or sleeping pills
Codeine or other narcotics
Latex materials
Local anesthetics (“Novocain”)
Penicillin or other antibiotics
Sulfa drugs
Other
Are you taking any of the following? Check all that apply.
Antibiotics or sulfa drugs
Anticoagulants (blood thinners)
Antidepressants or tranquilizers
Aspirin
Cortisone or other steroids
High blood pressure medicine
Insulin, Orinase, or other diabetes drug Nitroglycerin
Osteoporosis (bone density) medicine
Other
Women
May be pregnant
Taking hormones or contraceptives
If pregnant, what is your expected delivery date?
-
Month
-
Day
Year
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Physician's Name
Phone
Phone
Pharmacy
Phone
Phone
Do you have artificial joint(s), valve(s)?
Yes
No
If YES, please provide additional information.
If YES, do you need to take an antibiotic prior to dental treatment?
Yes
No
Do you have any disease, condition, or problem not listed on this page?
Please add anything else you would like us to know.
Are you taking ANY drugs, medications, or treatments at this time? Please list.
Please list any over-the-counter (OTC) medications (such as Aspirin, Advil, allergy medications, sleeping aids, etc.) that you take.
Please list any vitamins, natural or herbal preparations and/or dietary supplements that you take.
Have you been hospitalized or had surgery in the last three years?
Yes
No
If YES, please give reason(s) for hospitalization and/or surgery and dates.
Please acknowledge that the
medical health history information provided is accurate and complete.
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Today's Date
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