Pre-Oral Surgery Medical History Form
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact Name
Emergency Contact Phone
Relationship to Emergency Contact
Medical History
Are you under a physician’s care?
Yes
No
If yes, please specify
Have you ever been hospitalized or had a major operation?
Yes
No
If yes, please specify
Have you had any allergic reactions? (medications, food, latex, etc.)
Yes
No
If yes, please list
List any medications you are currently taking
Do you smoke or use tobacco?
Yes
No
Do you consume alcohol?
Yes
No
Health Conditions
Please check any medical conditions that apply:
Heart Disease
Diabetes
High Blood Pressure
Blood Thinners
Asthma
Kidney Disease
Liver Disease
Bleeding Disorders
Pregnancy
Other
If other, please specify
Additional Information
Any concerns or information your surgeon should be aware of?
Signature
Date