Dental Patient Medical History Form
Personal Information
Full Name
Date of Birth
Phone Number
Email
Address
Medical Information
Are you currently under a physician’s care?
Yes
No
If yes, please explain:
Are you taking any medications?
Yes
No
If yes, please list them:
Do you have any allergies (including latex, medications, etc.)?
Yes
No
If yes, please specify:
Have you ever had any of the following? (Check all that apply)
Heart Disease
Diabetes
High Blood Pressure
Cancer
Asthma
Epilepsy
Bleeding Disorders
Arthritis
HIV/AIDS
Other
If other, please specify:
Have you had any surgeries or hospitalizations?
Yes
No
If yes, please list and give dates:
Do you use tobacco products?
Yes
No
Do you drink alcohol?
Yes
No
For Women
Are you pregnant or nursing?
Yes
No
If pregnant, how many weeks?
Additional Information
Is there anything else about your health we should know?