MEDICAL HISTORY (English)
Emergency Contact
City/State:
Name of Medical Doctor:
Birthdate:
First Name:
Last Name:
Y
N
N
Y
Are you allergic to any of the following?
Unusual reaction to dental injections?
Reason for today`s visit
Date of last cleaning and exam
City/State
Name of former dentist
Do you have BiteWing x-rays that are less than 1 year old?
New patients:
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
Are you in pain?
Kidney Disease
Pregnancy
Cancer
Liver Disease
Bleeding Problems
Diabetes
Heart Trouble
Sinus Trouble
Heart Murmur
Psychiatric Treatment
Medical History for New Patients
Date: 4/26/2024
Rheumatic Fever
Tobacco use? If so, what kind and how much?
Joint Replacement
Stroke
Ulcers
High Blood Pressure
Anesthetic
Penicillin
Asthma
N
N
Y
Y
Do you have any of the following medical conditions?
Sulfa
Ibuprofen
List all medications that you are now taking:
Relationship
Phone
Iodine
Aspirin
Latex
Codeine
Signature will be recorded later.