Medical History English
Date: 3/29/2024
Signature will be recorded later.
If yes, Please explaine
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release my information including diagnosis and the records to any treatment or examination rendered to my child or me during the period of such dental care to third party payers and/or health practitioners. I consent to the dental x-rays, diagnostic procedures and treatment by the dentist necessary for proper dental care.
Have you ever been hospitalized for any surgical operation or serious illness within last 5 yrs?
Are you taking any Blood Thinner?.................................................................................................
Have you ever taken phen phen?...................................................................................................
Are you taking any oral contraceptive?.........................................................................................
Are you pregnant or think you may be preganant? ....................................................................
Y
N
Do you have any other medical conditions that is not listed above?
Thyroid Problem
Low Blood Pressure
Stomach Ulcer
Rheumatic Fever
Joint Replacement
Mitral Valve Prolapse
Ulcers
High Blood Pressure
AIDS / HIV Infection
Heart Disease
Stroke
Leukemia
Sinus Trouble
Heart Murmur
Hepatitis/Jaundice
Radiation Therapy
Anxiety
Diabetes
Angina
Osteoporosis
Cancer
Heart Attack
Liver Disease
Bleeding Problems
Fainting / Seizures
Kidney Disease
Asthma
N
Y
Y
N
N
Y
Do you have any of the following medical conditions?
Codeine
Latex
Sulfa
Aspirin
Penicillin
Ibuprofen
Anesthetic
Iodine
Any Metal
N
Y
N
Y
N
Y
Are you allergic to any of the following?
List all medications that you are now taking:
Relationship
Phone
Emergency Contact
City/State:
Name of Medical Doctor:
Birthdate:
First Name:
Last Name:
Medical History for New Patient