Medical History Form

Personal Physician's Name

Address

Phone

The approximate date of your last doctors visit

Your current physical health is

Good

Fair

Poor

Are you currently under the care of any physician?

Yes

No

If yes, please explain

Do you smoke or use tobacco in any other form?

Yes

No

Are you presently taking any drugs prescribed by a physician or dentist?

Yes

No

If yes. please list

Are you taking aspirin?

Yes

No

Are you taking blood thinners?

Yes

No

Are you pregnant?

Yes

No

Are you taking birth control pills?

Yes

No

Have you been told that you need to take antibiotics before any dental procedure?

Yes

No

Have you had any serious medical problems in the last 5 years?

Yes

No

If yes. please list

Have you ever had any of the following diseases or medical problems?

Doctor's Comments

Any other serious medical conditions:

Have you experienced any that are not listed above

Yes

No

If yes, please list

Are you allergic to any of the following?

Penicillin

Y

N

Dental Anesthetics

Y

N

Latex

Y

N

Aspirin

Y

N

Tetracycline

Y

N

Metals

Y

N

Acrylics

Y

N

Opioids like Codeine/Hydrocodone

Y

N

Are you allergic to any other drugs?

Yes

No

If yes, please list