MEDICAL HISTORY

 
 
 

Please complete the Medical History form below before you arrive OR you can download a printable form here. We look forward to seeing you, and raising the bar Sky high on your dental care!
 

Name *
Name
Are you having pain or discomfort at this time?
Do you feel very nervous about having dental treatment?
Have you ever had a bad experience in a dental office?
Have you been a patient in the hospital during the past two years?
Have you been under the care of a medical doctor during the past two years?
Have you taken any medicine or drugs during the past two years?
Are you allergic to (i.e., itching, rash, swelling of hands, feet or eyes) or made sick by penicillin, aspirin, codeine, or any drugs or medications?
Have you had any excessive bleeding requiring special treatment?
Are you currently taking Cumedin, Warfarin or any other blood thinners?
Are you currently, or in the past, taken any of the following: Fosamax, Actonel, Boniva, Zometa, or Aredia?
Check any of the following, which you have had or have at present time:
When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, or shortness of breath, or because you are very tired?
Do your ankles swell during the day?
Do you use more than 2 pillows to sleep?
Have you lost or gained more than 10 pounds in the past year?
Do you ever wake up from sleep short of breath?
Are you on a special diet?
Has your medical doctor ever said you have cancer or a tumor?
Do you have any disease, conditions, or problems not listed?
Have you ever had tonsillectomy (tonsils taken out?)
Check any of the following childhood diseases you have had:
Check any of the following products you have used:?
Women:
Are you pregnant now?
Are you taking birth control pills?
Do you anticipate becoming pregnant
To my knowledge, the above information is correct