Patient Medical History & Wellness Profile "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Medical HistoryName of Physician*PhoneDate of Last Exam MM slash DD slash YYYY Medical Conditions Heart Problems Heart Murmur Require Pre-medication Prior to Dental Treatment High Blood Pressure Pacemaker Allergy to Penicillin Latex Allergy Asthma Tuberculosis Hepatitis (Type A B C) Diabetes Dry Mouth Tobacco Use HIV or AIDS Venereal Disease Artificial Joints Cancer Epilepsy Mental Disorders Stroke Excessive Bleeding Glaucoma Other AllergiesPregnant? Due Date: MM slash DD slash YYYY Other Medical ConditionsPlease List Any Medications You Are Currently On:Have you ever had complications following dental treatment? Yes No If Yes Please Explain:Have you been admitted to the hospital in the past two years? Yes No If Yes Please Explain:Dental HistoryName of Previous Dentist:Last Dental Exam MM slash DD slash YYYY Do you have any of the following? Sensitivity to Cold or Heat Sensitivity to Sweet Sensitivity to Biting Pain in Any of Your Teeth Swelling in Your Face or Mouth Problems With Previous Dental Treatment Bleeding Gums Loose Teeth Do you like your smile? Yes No If No Please Explain:CommentsTo the best of knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment.Patient SignaturePatient Date MM slash DD slash YYYY Doctor SignatureDoctor Date MM slash DD slash YYYY * I understand that my information will be transmitted securely and used only for my care. Read Our practice's Privacy Policy / Notice of Privacy Practices Δ
