Oral Surgery Medical History Form
Patient Information
Full Name
Date of Birth
Phone
Email
Address
City
State
ZIP Code
Emergency Contact
Name
Relationship
Phone
Primary Physician
Physician Name
Phone
Medical History
Diabetes
Asthma
High Blood Pressure
Heart Disease
Other
If you checked 'Other', please specify
Allergies
Current Medications
Have you ever been hospitalized?
Yes
No
If yes, reason
Dental History
Have you had previous oral surgeries?
Yes
No
If yes, please explain
Main concern or reason for visit
Signature
Signature
Date