Medical/Dental History
Patient Name
Date
-
Month
-
Day
Year
Date
How would you rate your medical health?
Excellent
Average
Poor
How would you rate your dental health?
Excellent
Average
Poor
Please CIRCLE “YES” OR “NO” to indicate if you have had any of the following
Do you require antibiotics before dental treatment?
Yes
No
PRE-MED DOSAGE
Yes
No
Bleeding abnormally
Chest pain (Angina)
Diabetes
High Blood Pressure
Kidney Disease
Liver Disease
Mitral valve problems
Stent
Anemia
Arthritis Rheumatism
Yes
No
Artificial Heart Valves
Back Problems
Stroke
Chemotherapy
Congenital heart lesions
Cortisone Treatment
Persistent cough, or blood
Epilepsy
Fainting / dizziness
Headaches
Yes
No
Herpes
Human papilloma virus
Pacemaker
Radiation Treatment
Respiratory Problems
Sinus Problems
Tuberculosis
Ulcers
Unexplained
Weight Loss
AIDS / HIV
Yes/ No
Specify
Heart Conditions
Yes
No
Artificial Joints
Yes
No
Blood Transfusion Date
Yes
No
Cancer
Yes
No
Hepatitis Type
Yes
No
Substance Abuse
Yes
No
Other
Yes
No
Submit
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