Medical History Form

1
What is the best way to reach you?
2
Email
example@example.com
3
Cell Phone Number
Area Code
Phone Number
4
Other Phone Number
Area Code
Phone Number
5
Name
First Name
Last Name
6
Date of birth
Date
Year
Month
Day
7
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Marital Status
9
Your Occupation
10
Your Employer
11
Business Phone Number
Area Code
Phone Number
12
Your Spouse's name
13
Your Spouse's Occupation
14
Your Spouse's Employer
15
Your Spouse's Business Phone Number
Area Code
Phone Number
16
Are you covered by any type of insurance? If so, mention it here.
17
Name of your physician:
18
Please tell us who referred you to our office or how you heard about us.
19
Have you had any surgeries?
YESNO
20
Have you been in the hospital in the past year?
YESNO
21
Have you had a medical examination in the past 2 years?
YESNO
22
Are you presently taking any kind of medicine or drugs?
YESNO
23
Please list them here: (Including birth control)
24
Are you allergic to penicillin, codeine, aspirin, or any drug or medicine?
YESNO
25
Please list them here:
26
Have you ever had excessive bleeding requiring special treatment?
YESNO
27
Have you had arthritis?
YESNO
28
Have you had asthma?
YESNO
29
Have you had heart trouble/infection?
YESNO
30
Have you had radiation treatment?
YESNO
31
Have you had a stroke?
YESNO
32
Have you had epilepsy/seizure?
YESNO
33
Have you had osteoporosis?
YESNO
34
Have you had thyroid disorder?
YESNO
35
Have you had kidney disease?
YESNO
36
Have you had tuberculosis?
YESNO
37
Have you had high blood pressure?
YESNO
38
Have you had anemia?
YESNO
39
Have you had hepatitis?
YESNO
40
Have you had sinus trouble?
YESNO
41
Have you had low blood pressure?
YESNO
42
Have you had latex allergy?
YESNO
43
Have you had depression?
YESNO
44
Have you had AIDS?
YESNO
45
Have you had diabetes?
YESNO
46
Have you had heart murmurs?
YESNO
47
Have you had congenital heart lesions?
YESNO
48
Have you had rheumatic fever?
YESNO
49
Have you had surgery to replace a hip, knee or other joint?
YESNO
50
Have you ever had any bisphosphonate treatment for cancer or bone problem?
YESNO
51
Have you had surgery for heart valve replacement or pacemaker?
YESNO
52
(Women) Are you pregnant?
YESNO
53
Is there anything that the dentist should know regarding your medical history?
54
Do you smoke?
YESNO
55
If So, how many cigarettes a day?
56
Do you consume alcohol on a regular basis?
YESNO
57
If so, how many drinks per week?
58
Do you use recreational drugs?
YESNO
59
If so, how often are your using these?
60
What dental condition, if any, concerns you at present?
61
What is the history of this condition?
62
Approximate date of your last dental visit? And what was the nature of your visit?
63
Have you had any problems with local anaesthetic (freezing)?
YESNO
64
Do your gums feel tender or swollen?
YESNO
65
Do they ever bleed when brushing?
YESNO
66
Do you chew easily and thoroughly?
YESNO
67
Do you have any loose teeth?
YESNO
68
Do you have any trouble with opening or closing your mouth?
YESNO
69
Do you favor one side when chewing?
YESNO
70
Do you clench or grind your teeth?
YESNO
71
Are you satisfied with the appearance of your teeth?
YESNO
72
Are you tense during your dental visits?
YESNO
73
Have you ever had an upsetting experience at a dental visit?
YESNO
74
Is there anything about a dental treatment that bothers you?If so, please explain here:
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.