Medical History

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Patient Name: Last Name First Name Initial Birthdate: Month Day Year
E-mail Address:
Physician's name: Telehone: () -
Address: City: State: Zipcode:
Are you under a physician's care? 
If YES, how long:
If YES, why:
When was your last complete physical exam?

Select YES or NO, if you don't know the answer you may leave it blank.

Are you taking any medications or substances? 
Do you routinely take health related substances? 
Are you allergic to any medications or substances? 
Do you have problems with penicilin/antibiotics/anesthetics? 
Are you sensitive to any metals or latex? 
Are you pregnant or suspect you may be? 
Do you use any birth control medicaiton? 
Have you been treated/told you might have heart disease? 
Do you have a pacemaker or artificial heart valve implant? 
Have you ever had rheumatic fever? 
Are you aware of any heart murmurs? 
Do you have high or low blood pressure? 
Have you ever had a serious illness or major surgery? 
If YES, explain:
Have you ever had radiation treatment, chemo, growth or other condition? 
Do you have inflamatory disease such as arthritis or rheumatism? 
Do you have any artificial joints/prosthesis? 
Do you have any blood disorders such as anemia, leukemia? 
Have you ever bled excessively after being cut or injured? 
Do you have any stomach problems? 
Do you have any kidney problems? 
Do you have any liver problems? 
Are you diabetic? 
Do you have asthma? 
Do you have epilepsy or siezure disorders? 
Do you or have you had venereal disease? 
Have you tested HIV positive? 
Do you have AIDS? 
Have you had or do you test positive for hepatitis? 
Do you or have you had T.B.? 
Do you smoke, chew, use snuff or any other forms of tobacco? 
Do you consume alcoholic beverages? 
Do you habitually use controlled substances? 
Have you had psychiatric treatment? 
Do you have any disease, condition not listed? 
If YES, explain:
Is there anything else we should know about your health?
Would like to speak to the doctor privately about any problem? 

Release:

I certify that the above information is complete and accurate

Patient/Parent's Signature _________________________________________________________ Date: _______________________

Dentist's Signature _________________________________________________________ Date: _______________________


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Please review the information you are about to submit for accuracy. Thank you!