Name*
Name:
Phone*
Phone:
Email*
Email:
Best Time
Best Time:
Morning
Mid-day
Afternoon
Reason for Visit
Reason for Visit:
Cleaning
Whitening
Root Canal
Other
Submit
Email*
Email:
Submit
Medical History Form
Name:
Date and reason for last health care exam:
Are you under the care of a physician?
Yes
No
If so, what conditions are being treated.
Physician Name
Have you been hospitalized or had a serious operation or illness within the last 5 years?
Yes
No
Are you taking any prescription medication?
Yes
No
If yes, list any medication:
Are you taking Tagament(cimetidine)?
Yes
No
Do you take Antacids?
Yes
No
Are you taking any herbal supplements/medicines?
Yes
No
If yes, which ones?
Diet: Restricted Diet
Yes
No
How many meals per day?
Food allergies
Sugar in your diet?
None
Slight
Moderate
High
Do you consume grapefruit juice, grapefruits or extract?
Yes
No
When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest?
Yes
No
Do your ankles swell during the day?
Yes
No
Are you a smoker?
Yes
No
If yes, how much per day?
Are you required to Pre-medicate before dental work?
Yes
No
Do you have any of the following diseases or problems? Please check any that apply:
Aids/HIV-related disorders
Alcohol/Drug Abuse
Anemia
Arthritis
Asthma
Artificial Bones/Joints/Valves
Angina Pectoris
Blood Transfusion
Cold Sores
Cortisone Medicine
Diabetes
Congenital Heart Defect
Difficulty Breathing
Emphysema
Epilepsy/Seizures
Fainting/Dizzy Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack
Heart Murmur
Hepatitis
Herpes/Fever Blister
High Blood Pressure
Kidney problems
Latex Sensitivity
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Rheumatic Fever
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
TMJ
Tuberculosis (TB)
Ulcers
Venereal Disease
X-ray/cobalt treatment
I have read the above and do not have any problems/diseases
Are you allergic to any drugs or medication?
Yes
No
If yes, please check any that apply:
Aspirin
Codeine
Darvon
Demerol
Erythromycin
Local Anesthetic
Nembutal/Seconal
Nitrous Oxide
Novocain
Penicillin
Perodan
Other Antibodies
Scopolamine
Sleeping Pills
Tetracycline
Valium
Jewelry/Metals
Other
For women only:
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking birth control?
Yes
No
Submit
Medical History Form
Name
Name:
Reason for last health care exam*
Date and reason for last health care exam:
Under care of physician
Are you under the care of a physician?
Yes
No
Under care of physician comment
If so, what conditions are being treated.
Physician name
Physician Name
Hospitalized or serious injury
Have you been hospitalized or had a serious operation or illness within the last 5 years?
Yes
No
Perscription medication
Are you taking any prescription medication?
Yes
No
Persicription medication comment
If yes, list any medication:
Are you taking Tagament(cimetidine)?
Are you taking Tagament(cimetidine)?
Yes
No
Do you take Antacids?
Do you take Antacids?
Yes
No
Herbal supplements/medicines
Are you taking any herbal supplements/medicines?
Yes
No
Herbal supplements/medicines comment
If yes, which ones?
Diet
Diet: Restricted Diet
Yes
No
Meals per day
How many meals per day?
Food allergies
Food allergies
Sugar in your diet
Sugar in your diet?
None
Slight
Moderate
High
Grapefruit consumption
Do you consume grapefruit juice, grapefruits or extract?
Yes
No
Pain in your chest
When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest?
Yes
No
Ankle swelling
Do your ankles swell during the day?
Yes
No
Smoker
Are you a smoker?
Yes
No
Smoker comment
If yes, how much per day?
Pre-medicate
Are you required to Pre-medicate before dental work?
Yes
No
Deseases/Problems
Do you have any of the following diseases or problems? Please check any that apply:
Aids/HIV-related disorders
Alcohol/Drug Abuse
Anemia
Arthritis
Asthma
Artificial Bones/Joints/Valves
Angina Pectoris
Blood Transfusion
Cold Sores
Cortisone Medicine
Diabetes
Congenital Heart Defect
Difficulty Breathing
Emphysema
Epilepsy/Seizures
Fainting/Dizzy Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack
Heart Murmur
Hepatitis
Herpes/Fever Blister
High Blood Pressure
Kidney problems
Latex Sensitivity
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Rheumatic Fever
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
TMJ
Tuberculosis (TB)
Ulcers
Venereal Disease
X-ray/cobalt treatment
I have read the above and do not have any problems/diseases
Allergy to drugs
Are you allergic to any drugs or medication?
Yes
No
Drug allergy check list
If yes, please check any that apply:
Aspirin
Codeine
Darvon
Demerol
Erythromycin
Local Anesthetic
Nembutal/Seconal
Nitrous Oxide
Novocain
Penicillin
Perodan
Other Antibodies
Scopolamine
Sleeping Pills
Tetracycline
Valium
Jewelry/Metals
Other
Form women only:
Pregnant
Are you pregnant?
Yes
No
Nursing
Are you nursing?
Yes
No
Birth control
Are you taking birth control?
Yes
No
Submit
Copyright © 2010 Scott W. Grant, DMD
