Medical History Form Physician’s Name: Phone Number: Healthcare Card Number: 1. Has there been any change in your general health in the last year? YesNo 2. When was your last medical examination? (mm/dd/yyyy) 3. Are you presently being treated by a physician? YesNo If yes, why: 4. Have you been hospitalized or had a serious illness within the last 5 years? yesno If yes, why: 5. Have you had any (or exposure to any) of the following conditions: hepatitis / jaundice / liverpositive testing for HIV virusrheumatic fever / heart diseasecancer or tumorinflammatory rheumatismhigh / low blood pressurediabetestuberculosisblood / circulatory disordersvenereal diseasearthritiskidney diseaseasthma or hay feverfainting spells or seizuresstomach ulcerssinus troubleAIDS Other: 6. What medications are you presently taking? (prescribed or over the counter?) antibioticsanticoagulantshigh blood pressure medicationcortisone (steriods)tranquilizersantihistaminesaspirin or pain medicationinsulindigitalis or drugs for heartvitaminsnitroglycerin Homeopathic or Herbal Remedies (please list:) OTHER (please list): FOR WOMEN ONLY: hormonal therapyoral contraceptives 7. Do you have any instructions from a physician to take pre-medication for dental work? If so what are they? 8. Have you ever had any unusual reactions to the following: aspirinsedatives / sleeping pillspenicillin or other antibioticslocal anestheticsiodinecodeinesulfametals (gold, etc.) Other Medications: 9. Do you have any other allergies? yesno What are they?: 10. Do you bleed excessively when cut?: yesno 11. Do you smoke?: yesno 12. (WOMEN) Are you pregnant at the present time?: yesno If yes your due date?: 13. Is there anything regarding your health that we have not discussed that would be important for us to know before we begin? CONSENT: I hereby authorize the Doctor, upon consultation and direct consent from me to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of my dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication and therapy that may be indicated in connection with my case and in consultation with me and with my direct consent. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements including insurance or otherwise have been made. By entering your name checking the box below you are confirming your consent to the above. Please Enter Your Full Name: Checking here indicates consent (Required to submit form) To send this form please select the Cup.