Comprehensive Oral Surgery Medical History Form

Patient Information

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

Medical History

Current Health Status

• Primary Care Physician: _________________ Phone: _________________
• Date of Last Physical Exam: _________________
• Current Height: _______ Current Weight: _______

Medical Conditions (Check all that apply)

□ Heart Disease/Murmur □ High Blood Pressure □ Diabetes (Type: ___) □ Bleeding Disorders □ Respiratory Disease □ Liver Disease □ Kidney Disease □ Arthritis □ Cancer (Type: ___) □ Seizures/Epilepsy

Medications

• Current Medications: __________________________________
• Anticoagulants/Blood Thinners: □ Yes □ No
• Bisphosphonates History: □ Yes □ No

Allergies

□ Local Anesthetics □ Penicillin/Antibiotics □ Latex □ Other: _________________

Women Only

• Pregnant: □ Yes □ No
• Nursing: □ Yes □ No
• Birth Control: □ Yes □ No

Dental History

• Reason for Visit: _________________
• Previous Oral Surgery: □ Yes □ No
• Details: _________________

Lifestyle

• Tobacco Use: □ Yes □ No Type: _____ Frequency: _____
• Alcohol Use: □ Yes □ No Frequency: _____

Certification

I certify that the information provided is complete and accurate.

Signature: _________________ Date: _________________