Medical History Name*NicknameDate of Birth Date Format: MM slash DD slash YYYY SexMaleFemaleHeight (ft. / in.)Weight (lbs)For the following questions, select YES or No, whichever applies. Your answers are for our records only and will be considered confidential.1. Are you in good health?YesNo2. Has there been any change in your general health within the past year?YesNo3. My last physical examination was on4. Are you now under the care of a physician?YesNowhat is the condition being treated?*5. The name and address of my physician(s) is6. Have you had any serious illness, operation or been hospitalized within the past 5 years?YesNoWhat was the illness or problem?7. Are you taking any medicine(s)including non-prescription medicine?YesNoWhat medicine(s) are you taking?8. Do you have or have you had any of the following diseases or problems?a. Damaged heart valves or artificial heart valves, including heart murmur or rheumatic heart disease?YesNob. Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke)YesNo1. Do you have chest pain upon exertion?YesNo2. Are you ever short of breath after mild exercise or when lying down?YesNo3. Do your ankles swell?YesNo4. Do you have inborn heart defects?YesNo5. Do you have a cardiac pacemaker?YesNoc. Asthma or hay feverYesNod. Respiratory problems, emphysema, bronchitis, etc.YesNoe. TuberculosisYesNof. Viral infections and cold soresYesNog. DiabetesYesNoh. GlaucomaYesNoi. Hepatitis, jaundice, or liver diseaseYesNoj. Sexually transmitted diseaseYesNok. Aids or HIV infectionYesNol. Kidney troubleYesNom. Stomach ulcer or hyperacidityYesNon. Thyroid problemsYesNoo. Low blood pressureYesNop. Arthritis or painful, swollen jointsYesNoq. Problems of the immune systemYesNor. Epilepsy or other neurological diseaseYesNos. Fainting spells or seizuresYesNot. Persistent diarrhea or recent weight lossYesNou. CancerYesNov. Persistent cough or cough that produces bloodYesNow. Lumps or swelling in mouthYesNox. Persistent swollen glands in neckYesNoy. Radiation therapy or chemotherapyYesNo9. Have you had abnormal bleeding?YesNo10. Have you ever required a blood transfusion?YesNo11. Do you have any blood disorder such as anemia?YesNo12. Have you ever had any treatment for a tumor or growth?YesNo13: Are you allergic or have you had a reaction to:a. Local anestheticsYesNob. Penicillin or other antibioticsYesNoc. Sulfa drugsYesNod. Barbiturates, sedatives or sleeping pillsYesNoe. AspirinYesNof. IodineYesNog. Codeine or other narcoticsYesNoh. Other14. Have you had any problems with mental health?YesNo15. Have you had an alcohol or drug dependency?YesNo16. Do you use tobacco products?YesNo17. Are you wearing contact lenses?YesNo18. Do you have any disease, condition, or problem not listed above that you think I should know about?YesNoPlease explain19. Are you pregnant?YesNo20. Are you nursing?YesNo21. Are you taking birth control pills?YesNoI certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.Is patient a minor?*YesNoPatient SignatureGuardian Signature (patient is minor)Date Date Format: MM slash DD slash YYYY