Medical History Forms

Download Medical History Form (PDF) or fill out our online form below.

Medical History Form

Have you been a patient in a hospital during the past two years?

Have you been under a doctor's care during the past two years?

Do you take any medications or drugs i.e. aspirin, vitamins, hormones, antacids?

Are you allergic to penicillin or any other medicines or drugs?

Have you ever had any adverse reactions to any drugs, aesthetics, sedatives or narcotics?

Does aspirin or Ibuprofin (Motrin) irritate your stomach?

Have you been diagnosed as having any immunodeficiency, AIDS or HIV infection?

Are you required, due to your health, to restrict your work or activity in any way?

Are you on a special or restricted diet of any kind?

Are you taking any herbal supplements?

Do you use tobacco?

Do you drink alcohol?

Do you have a history of any substance abuse?

Check any of the following you may have had:

Has a physician directed you to take antibiotics prior to having dental treatment?

5 + 5 =

Periodontic & Dental Implant Specialists

With extensive training using the latest dental procedures
Schedule Appointment