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Medical History

Patient Name

Birthdate

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 medication that you may be taking, can affect your oral health and may be important for your dental care.

Are you under a physician's care now?

YesNo

Have you ever been hospitalized or had a major operation?

YesNo

Have you ever had a serious head or neck injury?

YesNo

Are you taking any medications, pills, or drugs?

YesNo

Do you take, or have you taken, Phen-Fen or Redux?

YesNo

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

YesNo

Are you on aspecial diet?

YesNo

Do you use tobacco?

YesNo

Do you use controlled substances?

YesNo

Women: Are you...

Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?

Are you allergic to any of the following?

AspirinMetalPenicillinLatexCodeineSulfa DrugsAcrylicLocal AnestheticsOther

Do you have, or have you had, any of the following?

AIDS/HIV Positive

YesNo

Alzheimer's Disease

YesNo

Anaphylaxis

YesNo

Anemia

YesNo

Angina

YesNo

Arthritis/Gout

YesNo

Artificial Heart Valve

YesNo

Artificial Joint

YesNo

Asthma

YesNo

Blood Disease

YesNo

Blood Transfusion

YesNo

Breathing Problems

YesNo

Bruise Easily

YesNo

Cancer

YesNo

Chemotherapy

YesNo

Chest Pains

YesNo

Cold Sores/Fever Blisters

YesNo

Congenital Heart Disorder

YesNo

Convulsions

YesNo

Cortisone Medicine

YesNo

Diabetes

YesNo

Drug Addiction

YesNo

Easily Winded

YesNo

Emphysema

YesNo

Emphysema

YesNo

Epilepsy or Seizures

YesNo

Excessive Bleeding

YesNo

Excessive Thirst

YesNo

Fainting Spells/Dizziness

YesNo

Frequent Cough

YesNo

Frequent Diarrhea

YesNo

Frequent Headaches

YesNo

Genital Herpes

YesNo

Glaucoma

YesNo

Hay Fever

YesNo

Heart Attack/Failure

YesNo

Heart Murmur

YesNo

Heart Pacemaker

YesNo

Heart Trouble/Disease

YesNo

Hemophilia

YesNo

Hepatitis A

YesNo

Hepatitis B or C

YesNo

Herpes

YesNo

High Blood Pressure

YesNo

High Cholesterol

YesNo

Hives or Rash

YesNo

Hypoglycemia

YesNo

Irreqular Heartbeat

YesNo

Kidney Problems

YesNo

Leukemia

YesNo

Liver Disease

YesNo

Low Blood Pressure

YesNo

Lung Disease

YesNo

Mitral Valve Prolapse

YesNo

Osteoporosis

YesNo

Pain in Jaw Joints

YesNo

Parathyroid Disease

YesNo

Psychiatric Care

YesNo

Radiation Treatments

YesNo

Recent Weight Loss

YesNo

Renal Dialysis

YesNo

Rheumatic Fever

YesNo

Rheumatism

YesNo

Scarlet Fever

YesNo

Shingles

YesNo

Sickle Cell Disease

YesNo

Sinus Trouble

YesNo

Spina Bifida

YesNo

Stomach/Intestinal Disease

YesNo

Stroke

YesNo

Swelling of Limbs

YesNo

Thyroid Disease

YesNo

Thyroid Disease

YesNo

Tuberculosis

YesNo

Tumors or Growths

YesNo

Ulcers

YesNo

Venereal Disease

YesNo

Yellow Jaundice

YesNo

Have you ever had any serious illness not listed above?

YesNo

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 status.

Signature of Patient, Parent or Guardian:

Date:

By submitting this form I have read and acknowledged the Privacy policy.

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1635 Rosecrans St Ste A,
San Diego, CA 92106
Phone: (619) 223-3811

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Tuesday 8:00am - 5:00pm
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Thursday 9:00am - 6:00pm
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