Patient Name *
Patient Name
Medical Health History: Do you have, or have you had, any of the following? (select one)
Fainting Spells, Seizures, or Epilepsy
Frequent or severe headaches
Thyroid problems
Persistent cough or swollen glands
Heart Problems: Chest pain
Shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medication
Rheumatic fever
Artificial heart valve
Blood Problems: Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease (anemia)
Ever require a blood transfusion?
Allergy Problems: Hay fever
Sinus problems
Skin rashes
Taking allergy medication
Intestinal Problems: Ulcers
Weight gain or loss
Special Diet
Kidney or bladder problems
Bone or Joint Problems: Arthritis
Thirsty or mouth is dry much of the time
Family history of diabetes
During the past 12 months, have you taken any of the following?
Antibiotics or sulfa drugs
Anticoagulants (e.g., Coumadin)
High blood pressure medicine
Insulin, Orinase, or similar drug
Digitalis or drugs for heart trouble
Cortisone (steroids)
Natural remedies
Nonprescription drug/supplements
Premedications required by physician:
Local anesthetics (“Novocaine”)
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Tuberculosis or other respiratory disease
Do you drink alcohol?
Do you smoke?
Hepatitis, jaundice, or liver trouble
Herpes or other STD
Do you wear contact lenses?
History of head injury?
Epilepsy or other neurological disease?
History of alcohol or drug abuse?
Do you have any disease, condition, or problem not listed previously that you feel we should know about?
Are you taking contraceptives or other hormones?
Are you nursing?
Are you pregnant?
Have you reached menopause?