Medical History Form

To assist the dentist and ensure your well being while undergoing treatment in our office please answer the following questions in detail.
Information will be considered confidential and for our records only.

IF YOU HAVE QUESTIONS OR DESIRE ASSISTANCE PLEASE ASK RECEPTIONIST.

Medical History

Prefix

First Name *

Middle Name

Last Name *

PRESENT PHYSICIAN’S NAME:

Phone

SPECIALIST PHYSICIAN’S NAME:

Phone

Are You Presently Under Doctors Care? WHY?YESNO

If yes, why?

Have you been under Doctor's care in the past-two years? Why?YESNO

If yes, why?

Have you taken any medications, pills or drugs in the past 2 years?YesNo

Are presently taking any medications, pills or drugs?YESNO

If yes, what?** If you have a long list of meds please bring them with you at time of appointment **

Have you been hospitalized in the past two years?YESNO

If yes, why?

When was your last complete physical examination?

When walking, do you ever have to stop because of pain in your chest or shortness of breath?YESNO

Do you experience problems with healing?YESNO

Have you ever had any type of surgery? What & When?YESNO

IF YES - What & When?

Do you wish to speak privately with the Doctor about any problem?YESNO

DO you smoke?YESNO

If yes, how much?

Ate you 0n a Prescription Diet?YESNO

Are you currently in good health?YESNO