Medical History
Fainting or Seizures
Anemia
Allergies
High Blood Pressure
Tuberculosis
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
Congenital Heart Problems
Sinus Trouble
New patients:
Are you in pain?
Unusual reaction to dental injections?
Tobacco use? If so, what kind and how much?
Please check any conditions that you have:
None
List all medications or drugs you are allergic to:
None
Relationship
Phone
List all medications or drugs you are now taking:
Emergency Contact
City/State:
Name of Medical Doctor:
Medical History
Do you have BiteWing x-rays that are less than 1 year old?
Name of former dentist
City/State
Date of last cleaning and exam
Signature will be recorded later.
Date: 4/25/2024
Rheumatic Fever
Heart Disease
Mitral Valve Prolapse
Asthma
Liver Disease
Diabetes
Arthritis, Inflammatory Rheumatism
Ulcers
Are you in good health?
Any changes in you health in last year?
Any condition we should know about?
Signature will be recorded later.
Sexually Transmitted Diseases
KidneyTroubles
Menstrual Problems
TMJ Problems
Are You Pregnant?
DR. init
First Name:
Last Name:
DOB