Form

3.0 Medical History Form

Patient First Name

Patient Last Name

Have you ever had any of the following?

ADD/ADHD

Dizziness

Herpes

Respiratory Problems

AIDS/HIV Positive

Down Syndrome

High Blood Pressure

Rheumatic Fever

Allergies (seasonal)

Drug Addiction

Hypoglycemia

Rheumatism

Anxiety/Panic

Epilepsy or Seizures

Jaundice

Sinus Problems

Asthma

Excessive Bleeding

Irregular Heartbeat

Spina Bifida

Autism

Fainting Spells

Kidney Problems

Stomach Problems

Blood Disease

Frequent Cough

Leukemia

Stroke

Cancer

Frequent Headaches

Liver Disease

Thyroid Disease

Chemotherapy

Glaucoma

Low Blood Pressure

Tuberculosis

Cold Sores/Fever Blisters

Head Injuries

Mental Disorders

Tumors or Growths

Congenital Heart Disorder

Heart Disease

Nervous Disorders

Ulcers

Convulsions

Heart Murmur

Pain in Jaw Joints

Venereal Disease

Developmentally Delayed

Hepatitis A

Pregnancy

Yellow Jaundice

Diabetes

Hepatitis B or C

Radiation Treatment

Do you have any serious illnesses not listed above?

If Yes

Do you have any drug allergies?

If Yes

If one of the below, please select.

Penicillin

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Amoxicillin

Is the patient currently taking any medications?

If Yes

Have you ever had any complications following dental treatment?

If Yes

Have you ever had any of the following?

Have you been admitted to a hospital or needed emergency care during the past two years?

If Yes

Do you have any health problems that need further clarification?

If Yes

Do you have a physician?

If Yes

Additional Comments:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health, I will inform the doctors at the next appointment, without fail.

Patient, Parent or Guardian