Medical History Form Please complete our patient registration form. If you would prefer to download it and print it CLICK HERE Patient Registration Name First Last Date of Birth Date Format: MM slash DD slash YYYY Social Security #Medicaid #AgeGenderPhone NumberEmail Emergency ContactHow did you hear of us?Do you have any dental concerns? Explain:Have you experienced any of the following? Abnormal Bleeding after surgery Alcoholism Angina Arthritis Artificial Implant / Joint / Valve Asthma Cancer Cardiac Pacemaker Chest Pains Cold Sores Diabetes Dizziness / Fainting Emphysema / COPD Epilepsy Excessive Bleeding Glaucoma Head Injuries Heart Disease Heart Failure / Attack Heart Murmur Hepatitis C High Blood Pressure HIV+, AIDS, STDs Hives / Skin Rash Jaundice Kidney Disease Leukemia Liver Disease Low Blood Pressure Mental Health Disorder Mitral Valve Prolapse Nervous Disorder Pacemaker Pregnancy Radiation Treatment Recent Weight Loss Respiratory Problem Have you ever been told to premedicate prior to a dental appointment?YesNoHave you ever been hospitalized? Why?Are you under medical treatment now? Why?Are you allergic to:* Latex Penicillin or other antibiotics Local anesthetics Codeine or other narcotics Sulfa drugs Barbiturates, sedatives, or sleeping pills No known allergies Are you taking any of the following? Aspirin Anticoagulants (blood thinners e.g. Coumadin) Antibiotics or sulfa drugs High blood pressure medicine Antidepressants or tranquilizers Insulin other diabetes drugs Nitroglycerin Cortisone or other steroids Osteoporosis (bone density) medicine Natural supplements Women: Are you pregnant or plan to become pregnant Taking hormones or contraceptives Current Medications:Do you smoke, vape, use tobacco, marijuana, or other drugs?YesNoPlease explain the type and frequencySignature*By signing below, I acknowledge the importance of a truthful medical history and realize that incomplete information may have an adverse effect on my treatment. To the best of my knowledge, the information above is complete and accurate
