Medical History
Family Dr. Family Dr phone no.
Yes No Question
1. Do you consider yourself to be in good health?
2. Have you seen a physician in the last year for a check up or exam? If yes, approximately when was that visit?
3. Have you ever had a serious illness or operation?
4. Are you taking any medication? If yes please list or email us a copy of a medication summary.
5. Are you taking herbal supplements? If yes please list.
6. Are you taking aspirin daily?
7. Do you have Hay Fever, Asthma, or Drug Allergies? If yes, please list and explain.
8. Do you smoke? If yes, how many cigarettes per day?
9. Have you been diagnosed with Diabetes? If yes, what type of Diabetes were you diagnosed with?
10. Do you require premedication prior to dental appointments?
11. Do you have abnormal blood pressure?
12. Do you bruise easily?
13. Do you have or have you ever had any of the following: Heart Problems, Lung Problems, Hepatitis A, B or C, History of Rheumatic Fever, AIDS/HIV, Heart Murmur, Anemia, Bleeding Problems, Stroke, Tuberculosis, Kidney Problems, Cancer, Pacemaker, Epilepsy, Artificial Hip, Knee or Joint Replacement, Heart Valve or any other condition that is not listed here?
14. WOMEN ONLY; Are you pregnant? If yes, please list your approximate due date
15. Is there anything else we should know about your medical history?
16. I, the undersigned, have completed the above questionnaire and/or update and it is accurate to the best of my knowledge. I also certify that I consent to the performing of dental treatment and procedures agreed to be necessary or advisable. I also agree to assume responsibility for fees associated with those procedures. I understand that during the course of treatment, unexpected difficulties may arise, resulting in an altered prognosis, or a change of proposed treatment. I also consent to the taking of diagnostic photographs or radiographs agreed to be necessary. I also consent to be contacted by email.
17. Have you had a positive test for the COVID-19 virus and/or are experiencing the following symptoms over the past 14 days (fever, runny nose, sore throat, dry cough, difficulty breathing, and/or loss of smell or taste)?
Signature: Date: