Comprehensive Dental Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Address: _________________ Phone: _________________
• Email: _________________ Emergency Contact: _________________

Medical History

Current Health Status

• Primary Care Physician: _________________ Phone: _________________
• Date of Last Physical: _________________
• Are you currently under medical treatment? □ Yes □ No

Medical Conditions

Please check if you have or have had any of the following:

□ High Blood Pressure □ Heart Disease □ Diabetes □ Arthritis □ Artificial Joints □ Cancer □ Hepatitis □ HIV/AIDS □ Bleeding Disorders □ Respiratory Problems

Medications

• Current Medications: _________________
• Allergies: _________________

Dental History

• Last Dental Visit: _________________
• Reason for Today's Visit: _________________

Women Only

• Are you pregnant? □ Yes □ No Week #: _____
• Are you nursing? □ Yes □ No

Certification

I certify that the above information is complete and accurate to the best of my knowledge.

Signature: _________________ Date: _________________

Office Use Only

Reviewed by: _________________ Date: _________________