Medical History Forms

Name*

Birthdate*

Age

Email*

Present Health

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

Yes
No

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

Yes
No

Do you take medicines or drugs - i.e. aspirin, vitamins, hormones, antacids?*

Yes
No

Medications

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

Yes
No

Allergic to Drugs

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

Yes
No

Adverse Reactions

Are you diabetic or borderline diabetic?*

Yes
No

Diabetic

If so, what is your current A1C and date taken:

Any immunodeficiency, AIDS, or HIV infection diagnosis?*

Yes
No

Are you required to restrict your work or activity in any way?*

Yes
No

Are you taking any blood thinners - i.e. Plavix, Warfarin, Aspirin, Eliquis?*

Yes
No

Do you use tobacco?*

Yes
No

Herbal Supplements

Do you drink alcohol?*

Yes
No

Herbal Supplements

Do you have a history of any substance abuse?*

Yes
No

Check any of the following which you may have had:

Heart trouble
Congenital Heart Lesions
Heart Murmur
Prolapsed Mitral Valve
Heart Surgery
Rheumatic Fever
Cardiac Pacemaker
Latex allergy
Heart Valve Prosthesis

High Blood Pressure
Low Blood Pressure
Glaucoma
Diabetes
Hepatitis or Jaundice
Ulcers
Kidney Disease
Psychiatric Care
Osteoporosis

Persistent Cough
Sinus Troubles
Tuberculosis
Asthma
Epilepsy
Arthritis
Stroke
History of oral or other cancer
Joint Replacement Prosthesis

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

Yes
No

If yes, please take your pre-med antibiotic as prescribed by your physician prior to your appointment

Physician's Name

Message*

Email

This field is for validation purposes and should be left unchanged.

Medical History Form

Periodontic & Dental Implant Specialists