Medical History Form

MEDICAL HISTORY

Date of last physical examination: Name of physician:

Are you under the care of a physician for a specific condition?

Yes

If so, what condition is being treated?

Have you been hospitalized during the past three years?

Yes

If so, what was the problem?

Are you taking any drugs or medicine?

Yes

If so, list drugs with dosages:

Are you sensitive or allergic to:

Penicillin

Erythromycin

Sulfa

Tetracycline

Codeine

Latex

Aspirin

Ibuprofen

Other drug allergies (please list)

Have you ever had an unfavorable reaction from a local anesthetic?

Yes

Have you ever been told to take antibiotics prior to your dental appointments?

Yes

Do you have or have you had any of the following, please mark the box:

Do you have any disease or condition not listed?

Yes

If so, what?

(Women) Are you pregnant or nursing?

Yes

(Women) Do you take birth control pills?

Yes

Are you nervous or anxious in the dental office?

Yes

If so, would you like to be treated with Nitrous Oxide?

Yes

CONSENT FOR TREATMENT: The above health history is correct to the best of my knowledge. I authorize and give consent for dental services agreed to by Doctor and Patient and/or Guardian, including the use of local anesthesia and other medications as indicated.

Patient, Guardian, or Parent Signature:

Doctor Signature:

Patient Validation:

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