Medical History Form

Patient Info

First Name

Last Name

Date / Time

Name of Medical Doctor

City / State

Emergency Contact

Phone

Relationship

Medications & Allergies

List all medications or drugs you are now taking:

List all medications or drugs you are allergic to:

List any medical conditions you may have including: asthma, bleeding problems, cancer, diabetes, heart murmur, heart trouble, high blood pressure, joint replacement, kidney disease, liver disease, pregnancy, psychiatric treatment, sinus trouble, stroke, ulcers, or history of rheumatic fever or of taking fen-phen:

New Patient / X-ray & Dental History

Tobacco use? If so, what kind and how much?

Unusual reaction to dental injections?

Reason for today's visit

Are you in pain?

Yes

Do you have a Panoramic x-ray or Full Mouth x-rays less than 5 years old?

Yes

Do you have BiteWing x-rays less than 1 year old?

Yes

Name of former dentist

City / State

Date of last cleaning and exam