Patient Medical History

Patient's Name*

First Last

Email*

Date of last complete physical [mm/dd/yyyy]*

Name of Physician*

First Last

Physician's Address*

Street Address City State / Province / Region ZIP / Postal Code

Physician's phone number*

Are you in good health?*

Yes
No

Do you or have you had any serious illness or operation?*

Have you ever been told that you require pre-medication for your dental appointments?*

Yes
No

If so, why?(If this does not apply, please indicate not applicable or n/a)*

Are you under the care of physician at the present time?*

Yes
No

Are you taking any medication?*

Yes
No

If so, please use medication list provided. (If this doesn't apply, please indicate n/a)*

Have you ever been warned against taking any medicines/drugs? If yes, please list. (If this doesn't apply, please indicate n/a)*

Are you on a special diet?*

Yes
No

what kind? (If this doesn't apply, please indicate n/a)*

Salt Restricted?*

Yes
No

Are you allergic to latex?*

Yes
No

Are you allergic to:*

Penicillin
Codeine
Local Anesthetic
Aspirin
Other drugs
Food/Colouring Dyes
Metals
Food
Not Applicable

Other?*

Have you had or have you been treated for any of the following?*

Other?*

Is there a history of family disease?*

Yes
No

If yes, please list.*

Do you get chest pains on exertions?*

Yes
No

Do your ankles swell?*

Yes
No

Have you noticed?*

Increased thirst
Increased frequency of urination
Unexplained weight loss
Other
Not Applicable

Other?*

women only - Are you pregnant?*

Yes
No
Maybe
Not Applicable

If yes, how many months?*

Are you on birth control?*

Yes
No
Not Applicable

Did you know that antibiotics reduce the effects of Birth Control Pills?*

Yes
No
Not Applicable

Patient or guardian signature*

I authorize treatment of the person named above and agree to pay all fees and charges for such treatment. I acknowledge that I am responsible for informing the doctor of any changes in my health history prior to treatment.

Date of Application*