Medical History Form

Patient's Name

Height

Weight

Gender

Date of Birth

Please describe your current health:
Excellent Good Fair Poor

Please describe the symptoms you are currently having today:

Have there been any changes in your general health in the past year?
Yes No

If yes, please describe:

Are you now under a doctor’s care for a particular problem at this time?
Yes No

If yes, why?

Date of last physical exam

Have you ever been hospitalized or had a serious illness?
Yes No

If yes, why?

Have you ever had surgery?
Yes No

If yes, when and what for?
Date of surgery: Reason for surgery:
Date of surgery: Reason for surgery:

Indicate which of the following you have had or have at present. Circle ”yes” or ”no” to each item

Congenital heart disease, cardiovascular disease
Yes No

Lung disease
Yes No

Implants placed anywhere in the body
Yes No

Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily?
Yes No

None of the Above

Kidney disease or kidney failure, requiring dialysis?
Yes No

Liver disease (jaundice, hepatitis A, B, or C)
Yes No

Thyroid disease
Yes No

Arthritis
Yes No

None of the Above

Stomach ulcers or colitis
Yes No

Significant weight loss or gain
Yes No

Clicking, popping, or pain within the jaw joint and/or difficulty opening mouth?
Yes No

Seizures, convulsions, epilepsy, fainting or dizziness? Y
Yes No

None of the Above

Frequent or recurring mouth sores
Yes No

Sinus or nasal problems
Yes No

Glaucoma
Yes No

Sleep apnea
Yes No

None of the Above

Diabetes
Yes No

Osteoporosis or osteopenia
Yes No

None of the Above

Any cancer, radiation, or chemotherapy?
Yes No

Describe:

Date of your last treatment?

Do you have any other disease, condition or problem not listed above that you think the doctor should know about?
Yes No

If yes, please explain:

Family Medical History
Do you have a family history of any of the following? If yes, indicate the relationship.

Diabetes?
Yes No

Relationship

Heart disease?
Yes No

Relationship

Tumors?
Yes No

Relationship

Sleep Apnea?
Yes No

Relationship

None of the Above

Cancer?
Yes No

Relationship

Bleeding problems?
Yes No

Relationship

Lung disease?
Yes No

Relationship

None of the Above

Female Patients

Are you pregnant, or is there any chance you might be pregnant?
Yes No

Relationship

Medications
Are you using any of the following:

Antibiotics?
Yes No

Anticoagulants (blood thinners)?
Yes No

Heart medications?
Yes No

Steroids (cortisone, prednisone, etc.)?
Yes No

None of the Above

Antianxiety agents, antidepressants or other psychiatric medications?
Yes No

Prescription pain medication?
Yes No

Aspirin or drugs such as Motrin, Aleve, Ibuprofen?
Yes No

Insulin or oral anti-diabetic drugs?
Yes No

None of the Above

Blood pressure medications?
Yes No

Bisphosphonates, medications to strengthen your bones, IV medications, or any other cancer drugs?
Yes No

If yes, list drugs used and time of use.

None of the Above

Please list any specific medications indicated above and/or any other medications not listed above that you are currently taking including prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins or minerals:

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage

Allergies
Are you allergic to or have you had an adverse reaction to:

Latex?
Yes No

Food products?
Yes No

Sedatives, barbiturates?
Yes No

None of the Above

Codeine or other pain killers?
Yes No

Aspirin, Motrin, Aleve, or ibuprofen?
Yes No

Penicillin or other antibiotics?
Yes No

None of the Above

Have you or an immediate family member had any problem associated with local anesthesia, general anesthesia, and/or intravenous sedation?
Yes No

If yes, which anesthetic?

Relationship?

Other drug or food allergies not listed above:

Social History

Have you ever smoked, vaped or chewed tobacco?
Yes No

If yes, for how long?

Have you ever sought professional care or been hospitalized for:

Substance abuse?
Yes No

Emotional disorders?
Yes No

Alcoholism?
Yes No

None of the Above

Do you use:

Alcohol?
Yes No

How often?

Marijuana?
Yes No

How often?

Recreational drugs?
Yes No

How often?

None of the Above

Dental History

Have you had any adverse effects from dental treatment?
Yes No

If Yes, please explain?

Do you wish to talk to the doctor privately about anything?
Yes No

Indicate which of the following you have had or have at present. Circle ”yes” or ”no” to each item

Family Medical History
Do you have a family history of any of the following? If yes, indicate the relationship.

Female Patients

Medications
Are you using any of the following:

Allergies
Are you allergic to or have you had an adverse reaction to:

Social History

Dental History

Contact Us

What Should I Expect? Wisdom Teeth Surgery

Dear valued patients,

Medical History Form

Indicate which of the following you have had or have at present. Circle ”yes” or ”no” to each item

Family Medical HistoryDo you have a family history of any of the following? If yes, indicate the relationship.

Female Patients

MedicationsAre you using any of the following:

AllergiesAre you allergic to or have you had an adverse reaction to:

Social History

Dental History

Contact Us

Family Medical History
Do you have a family history of any of the following? If yes, indicate the relationship.

Medications
Are you using any of the following:

Allergies
Are you allergic to or have you had an adverse reaction to: