Medical History

Skip to content

Home
Our Philosophy
Services
Patient Center
Meet Our Team
Contact Us

Name*
Nickname
Date of Birth
MM slash DD slash YYYY
Sex
- Male
- Female
Height (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?
- Yes
- No
2. Has there been any change in your general health within the past year?
- Yes
- No
3. My last physical examination was on
4. Are you now under the care of a physician?
- Yes
- No
what is the condition being treated?*
5. The name and address of my physician(s) is
6. Have you had any serious illness, operation or been hospitalized within the past 5 years?
- Yes
- No
What was the illness or problem?
7. Are you taking any medicine(s)including non-prescription medicine?
- Yes
- No
What 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?
- Yes
- No
b. Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke)
- Yes
- No
1. Do you have chest pain upon exertion?
- Yes
- No
2. Are you ever short of breath after mild exercise or when lying down?
- Yes
- No
3. Do your ankles swell?
- Yes
- No
4. Do you have inborn heart defects?
- Yes
- No
5. Do you have a cardiac pacemaker?
- Yes
- No
c. Asthma or hay fever
- Yes
- No
d. Respiratory problems, emphysema, bronchitis, etc.
- Yes
- No
e. Tuberculosis
- Yes
- No
f. Viral infections and cold sores
- Yes
- No
g. Diabetes
- Yes
- No
h. Glaucoma
- Yes
- No
i. Hepatitis, jaundice, or liver disease
- Yes
- No
j. Sexually transmitted disease
- Yes
- No
k. Aids or HIV infection
- Yes
- No
l. Kidney trouble
- Yes
- No
m. Stomach ulcer or hyperacidity
- Yes
- No
n. Thyroid problems
- Yes
- No
o. Low blood pressure
- Yes
- No
p. Arthritis or painful, swollen joints
- Yes
- No
q. Problems of the immune system
- Yes
- No
r. Epilepsy or other neurological disease
- Yes
- No
s. Fainting spells or seizures
- Yes
- No
t. Persistent diarrhea or recent weight loss
- Yes
- No
u. Cancer
- Yes
- No
v. Persistent cough or cough that produces blood
- Yes
- No
w. Lumps or swelling in mouth
- Yes
- No
x. Persistent swollen glands in neck
- Yes
- No
y. Radiation therapy or chemotherapy
- Yes
- No
9. Have you had abnormal bleeding?
- Yes
- No
10. Have you ever required a blood transfusion?
- Yes
- No
11. Do you have any blood disorder such as anemia?
- Yes
- No
12. Have you ever had any treatment for a tumor or growth?
- Yes
- No
13: Are you allergic or have you had a reaction to:
a. Local anesthetics
- Yes
- No
b. Penicillin or other antibiotics
- Yes
- No
c. Sulfa drugs
- Yes
- No
d. Barbiturates, sedatives or sleeping pills
- Yes
- No
e. Aspirin
- Yes
- No
f. Iodine
- Yes
- No
g. Codeine or other narcotics
- Yes
- No
h. Other
14. Have you had any problems with mental health?
- Yes
- No
15. Have you had an alcohol or drug dependency?
- Yes
- No
16. Do you use tobacco products?
- Yes
- No
17. Are you wearing contact lenses?
- Yes
- No
18. Do you have any disease, condition, or problem not listed above that you think I should know about?
- Yes
- No
Please explain
19. Are you pregnant?
- Yes
- No
20. Are you nursing?
- Yes
- No
21. Are you taking birth control pills?
- Yes
- No
I 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?*
- Yes
- No
Patient Signature
Guardian Signature (patient is minor)
Date
MM slash DD slash YYYY

Homepage Artwork by Dan McCoy. Rainier

Scroll To Top