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


  Last name

  MidI

  First name

Medical History

Allergies
HIV
Allergy - Aspirin
Jaundice
Allergy - Codeine
Kidney Disease
Allergy - Erythro
Liver Disease
Allergy - Hay Fever
Low Blood Pressure
Allergy - Latex
Mental Disorders
Allergy - Other
MVP
Allergy - Penicillin
Nervous Disorders
Allergy - Sulfa
Other
Anemia
Pacemaker
Arthritis
Pre-Med - Amox *
Artificial Joints
Pre-Med - Clind *
Asthma
Pre-Med - Other *
Blood Disease
Radiation Treatment
Cancer
Respiratory Problems
Diabetes
Rheumatic Fever
Dizziness
Rheumatism
Epilepsy
Sinus Problems
Excessive Bleeding
Stomach Problems
Fainting
Stroke
Glaucoma
Thyroid Problem
Head Injuries
Tuberculosis
Heart Disease
Tumors
Heart Murmur
Ulcers
Hepatitis
Venereal Disease
High Blood Pressure


A smoker or smoked previously
Ever been hospitalized (illness or injury)
FEMALE: Pregnant
FEMALE: Taking birth control pill
Presently being treated for any other illnesses
Taking dietary supplements
Taking medication for weight control (ie fen-phen)
Subject to frequent headaches

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

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.)