Medical History Form Fill Out Your Medical History Below "*" indicates required fields Step 1 of 2 50% First Name*MILast Name*Preferred NameEmail* Phone*Date of Birth* MM slash DD slash YYYY Indicate which of the following conditions you have or have had.Pre-Med Needed* Yes No AIDS/HIV* Yes No Allergy: Acetaminophen* Yes No Allergy: Adhesive* Yes No Allergy: Amoxicillin* Yes No Allergy: Aspirin* Yes No Allergy: Azithromycin Dihydra* Yes No Allergy: Bactrim* Yes No Allergy: Codeine* Yes No Allergy: Erythromycin* Yes No Allergy: Food* Yes No Allergy: Fentanyl* Yes No Allergy: Hydralazine* Yes No Allergy: Hydrocodone* Yes No Allergy: Ibuprofen Magonized* Yes No Allergy: Latex* Yes No Allergy: Levaquin* Yes No Allergy: Lido/Carbo* Yes No Allergy: Novacin* Yes No Allergy: Metronidazole HCL* Yes No Allergy: Morphine* Yes No Allergy: Peanuts* Yes No Allergy: Penicillin* Yes No Allergy: Tamsulosin HCL* Yes No Allergy: Tetracycline* Yes No Allergy: Tramadol* Yes No Allergy: Simbrinza* Yes No Allergy: Sulfa* Yes No Alzheimers* Yes No Anemia* Yes No Arthritis* Yes No Artificial Joints* Yes No Asthma* Yes No Bees* Yes No Blood Disease* Yes No COPD* Yes No Cancer* Yes No Cardiac Pacemaker* Yes No Ceclor* Yes No Chest Pain* Yes No Crohn's Disease* Yes No Dementia* Yes No Diabetes* Yes No Dry Mouth* Yes No Easily Winded* Yes No Emphysema* Yes No Epilepsy* Yes No Excessive Bleeding* Yes No Fainting* Yes No Frequently Tired* Yes No GERD* Yes No Glaucoma* Yes No Hay Fever* Yes No Head Injuries* Yes No Heart Attack* Yes No Heart Disease* Yes No Heart Murmur* Yes No Hepatitis/Jaundice* Yes No High Blood Pressure* Yes No Immune Disorder* Yes No Jaundice* Yes No Joint Replacement* Yes No Kidney Disease* Yes No Liver Disease* Yes No Low Blood Pressure* Yes No Mental Disorders* Yes No Mitral Valve Prolapse* Yes No Nervous Disorders* Yes No Osteoporosis* Yes No Pacemaker* Yes No Pregnancy/Nursing* Yes No Radiation/Chemo Tx* Yes No Reflux* Yes No Respiratory Problems* Yes No Rheumatic Fever* Yes No Rheumatism* Yes No Seizures* Yes No Sinus Problems* Yes No Stomach Problems* Yes No Stomach Ulcers* Yes No Stroke* Yes No Thyroid* Yes No Tobacco/Vapor Use* Yes No Tuberculosis* Yes No Tumors* Yes No VD/STD* Yes No Please explain/clarify any conditions or alerts selected above:Conditions/Alterts:Allergies not listed:Do you take antibiotic premedication for your dental visits? If yes, please explain below:* Yes No Pre-Med:* Name of Your PhysicianPhone NumberPreferred PharmacyPhone NumberDescribe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment below:Are you currently taking any medications (prescription and non-prescription) including regular doses of aspirin? if yes, please all medications and doses below:* Yes No Medications:*By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. This will serve as my electronic Signature.* I acknowledge the statement above.* THE FOLLOWING SECTION IS FOR EXISTING PATIENTS ONLY * Please review and update the following information if needed. Thank You.Chart #:FOR OFFICE USE ONLY ↑First NameMILast NamePreferred NameTitleMr/Ms/Mrs/etc.Gender Male Female Family Status Married Single Divorced Other Date of Birth MM slash DD slash YYYY Prev. Visit: MM slash DD slash YYYY Email Address Home PhoneMobile PhoneWork PhoneExtBest Time to CallMorning, Afternoon, etc.Address 1Address 2CityStatePlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip CodeCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
