Click on Calendar, type the year 'YYYY' and pick the month & date.
Medical and Dental History


  Last name

  MidI

  First name

Medical History

Pre-Med - Amox *
Pre-Med - Clind *
Pre-Med - Other *
Allergies
Allergy - Aspirin
Allergy - Codeine
Allergy - Erythro
Allergy - Hay Fever
Allergy - Latex
Allergy - Other
Allergy - Penicillin
Allergy - Sulfa
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
HIV
Jaundice
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorders
MVP
Nervous Disorders
Other
Pacemaker
Pregnancy
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Thyroid Problem
Tuberculosis
Tumors
Ulcers
Venereal Disease
Ever been hospitalized (illness or injury)
Presently being treated for any other illnesses
Taking medication for weight control (ie fen-phen)
Taking dietary supplements
Subject to frequent headaches
A smoker or smoked previously
FEMALE: Taking birth control pill
FEMALE: Pregnant

Do you take antibiotic premedication for your dental visits? Yes No
If Yes, Please Explain:

* By checking this box, I acknowledge that the above information is correct and I understand it is my responsibility to inform the office of any changes in my health as soon as possible.

Dental History

How would you rate the condition of your mouth?
Excellent Good Fair Poor
I routinely see my dentist every :
3 Months 4 Months 6 Months 12 Months Not routinely

Had an unfavorable dental experience
Had trouble getting numb
Had any reactions to local anesthetic
Had/Have braces, orthodontic treatment
Had your bite adjusted
Had any teeth removed
Had complications from past dental treatment

*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)