MEDICAL HISTORY FULL NAME PHYSICIAN’S NAME HOW IS YOUR GENERAL HEALTH? D.O.B. DATE OF LAST VISIT HEIGHT SEX WEIGHT PLEASE CHECK IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV ANEMIA ARTHRITIS, RHEUMATISM ARTIFICIAL HEART VALVES ARTIFICIAL JOINTS ASTHMA BACK PROBLEMS BLEEDING ABNORMALLY, WITH EXTRACTIONS OR SURGERY BLOOD DISEASE CANCER CHEMICAL DEPENDENCY CHEMOTHERAPY CIRCULATORY PROBLEMS CONGENITAL HEART LESIONS CORTISONE TREATMENTS COUGH, PERSISTENT OR BLOODY DIABETES EMPHYSEMA EPILEPSY FAINTING OR DIZZINESS GLAUCOMA HEADACHES HEART MURMUR HEART PROBLEMS HEPATITIS TYPE ____ HERPES HIGH BLOOD PRESSURE JAUNDICE JAW PAIN KIDNEY DISEASE LIVER DISEASE LOW BLOOD PRESSURE MITRAL VALVE PROLAPSE NERVOUS PROBLEMS OSTEOPOROSIS PACEMAKER PSYCHIATRIC CARE RADIATION TREATMENT RESPIRATORY DISEASE RHEUMATIC FEVER SCARLET FEVER SHORTNESS OF BREATH SINUS TROUBLE SKIN RASH SPECIAL DIET STROKE SWOLLEN FEET OR ANKLES SWOLLEN NECK GLANDS THYROID PROBLEMS TONSILITIS TUBERCULOSIS TUMOR OR GROWTH ON HEAD OR NECK ULCER VENERAL DISEASE WEIGHT LOSS, UNEXPLAINED ARE YOU CURRENTLY BEING TREATED FOR ANY MEDICAL CONDITIONS? IF YES, PLEASE EXPLAIN YES NO HAVE YOU HAD SURGERY OR BEEN HOSPITALIZED IN THE PAST YEAR? IF YES, PLEASE EXPLAIN YES NO WOMEN ARE YOU PREGNANT? YES NO DUE DATE ARE YOU NURSING? YES NO ALLERGIES ASPIRIN BARBITUATES CODEINE IODINE LATEX LOCAL ANESTHETIC OTHERS CONTINUED ON BACK PENICILLIN SULFA MEDICATIONS PLEASE LIST ALL MEDICATIONS AND SUPPLEMENTS YOU ARE CURRENTLY TAKING: TO BE TAKEN AT APPOINTMENT BLOOD PRESSURE (mmHG) PULSE (BPM) The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-‐compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician. I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. PATIENT’S SIGNATURE DATE DENTIST’S SIGNATURE DATE