Thank you for completing the patient information form. Please complete this Medical History form. Medical HistoryPhysician's NameDate of last physical Have you ever had any of the following conditions? (Check any that apply) Allergies Arthritis Artificial heart Valves or joints, screws, etc Radiation Treatment Recent Weight Loss respiratory Disease Rheumatic Fever Sinus Problems Special Diet Stroke Swollen Neck Glands Ulcer Venereal Disease Epilepsy Headaches Back Problems Bleeding Abnormally Blood Disease Cancer Chemical Dependency Chronic Diarrhea Circulatory Problems Heart Lesions Diabetes Asthma Pacemaker Psychiatric Care Heart Murmur Heart Problems Hemophilia Hepatitis, Jaundice Hernia Repair High Blood Preassure HIV/AIDS Low Blood Pressure Mitral Valve Prolapse Nervous Problems Do you have any drug allergies or have had any adverse reaction to any medication or anesthesia?YesNoIf so, what?Have you ever responded adversely to medical/dental treatment?YesNoIf so, what?Are you currently under the care of a physician?YesNoWhat conditions?If patient is a child, what is his/her weight?Is there anything else we should know about your medical history?Women OnlyDo you suspect that you are pregnant?YesNoAre you nursing?YesNoAre you taking birth control pills?YesNo
