Oral Surgery Patient History Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Phone Number
Email Address
Address
Referring Dentist / Doctor
Referring Dentist/Doctor Name
Medical History
Are you currently under medical care?
Yes
No
Physician's Name
List of current medications
Allergies
Major illnesses/conditions (diabetes, heart, etc)
Have you ever had any of the following? (Check all that apply)
Heart Disease
Diabetes
Asthma
Bleeding Disorder
Bone/Joint Disease
Other*
Surgical / Anesthesia History
Previous surgeries
Problems with anesthesia
Yes
No
Dental History
Are you in pain?
Yes
No
Reason for today's visit
Have you had problems with dental treatments before?
Yes
No
For Women
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Other Concerns or Information