Dental Patient Medical History Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact Name & Phone
Medical History
Are you currently under a physician's care?
Yes
No
If yes, please explain
Have you ever been hospitalized or had a major operation?
Yes
No
If yes, please explain
Do you have any allergies?
Please list current medications
Do you have or have you had any of the following?
Heart Disease
High Blood Pressure
Diabetes
Asthma
Bleeding Problems
Hepatitis
Epilepsy/Seizures
Kidney Disease
Stroke
Cancer
HIV/AIDS
Other
If other, please specify
Dentistry Related
Are you experiencing dental pain or discomfort?
Yes
No
Do your gums bleed when you brush or floss?
Yes
No
Other dental concerns
For Women
Are you pregnant?
Yes
No
If yes, how many weeks?
Are you nursing?
Yes
No
Are you taking birth control pills?
Yes
No
Additional Information
Signature
Date