Dental Implant Medical History Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Phone Number
Email Address
Address
Medical Information
Name of Physician
Physician's Phone
How would you describe your general health?
Excellent
Good
Fair
Poor
Are you currently under medical treatment?
Yes
No
Please list any medical conditions and/or recent hospitalizations
List all medications, vitamins, and supplements you are currently taking
Do you have any allergies? (medications, foods, etc.)
Medical Conditions (Check all that apply)
Diabetes
Heart Disease
High Blood Pressure
Low Blood Pressure
Bleeding Disorders
Osteoporosis
Cancer
Stroke
Thyroid Problems
Asthma
Other
If Other, please specify
Lifestyle
Do you smoke or use tobacco?
Yes
No
Former
Do you consume alcohol?
Yes
No
Dental History
Reason for dental implant consultation
Have you previously had dental implants?
Yes
No
Describe your current oral health
Consent & Signature
I confirm that the information provided is accurate to the best of my knowledge.
Signature
Date