Medical Health History

In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you have.

PATIENT INFORMATION

Title:

Patient Name:*

Date:

Name of family physician:

Date of last Medical:

Address of physician:

Phone number of physician:

A.Please select YES or NO to the following:

1.Are you in good health?

2.Has there been a change in your health within the last year?

If yes, please specify:

3. Have you been hospitalized or had a serious illness in the last 5 years?

If yes, please specify:

4. Are you being treated by a physician now?

If yes, please specify:

Name of additional physician(s):

B. Have you ever experienced?

Please select YES or NO to the following:

5. Chest Pains?

6. Swollen Ankles?

7.Shortness of breath?

8. Recent Weight loss, fever, night sweats?

9. Persistent cough, coughing up blood?

10. Bleeding problems, bruising easily?

11. Sinus Problems?

12. Difficulty swallowing?

13. Joint pain?

14. Stiffness?

15. Jaundice?

16. Dizziness?

17. Ringing in ears?

18. Frequent Headaches?

19. Fainting spells?

20. Blurred Vision?

21. Seizures?

22. Epilepsy?

23. Excessive thirst?

24. Frequent urination?

25. Dry Mouth?

26. Sleep Apnea?

27. Chronic snoring?

C. Have you ever experienced?

Please select YES or NO to the following:

28.Heart disease?

29. Heart attack?

30. Heart defects?

31. Heart murmur?

32. Rheumatic fever?

33. Mitral Valve Prolapse?

34. Hypertension (High Blood Pressure)?

35. Hypotension (Low Blood Pressure)?

36. Stroke?

37. Hardening of arteries?

38. Hepatitis A?

39. Hepatitis B?

40. Hepatitis C?

41. Stomach problems?

42. Ulcers?

43. Diabetes (Type I)?

44. Diabetes (Type II)?

45. Tuberculosis (TB)?

46. Emphysema?

47. Other lung diseases?

48. HIV positive?

49. AIDS?

50. Tumors?

51. Cancer?

52. Arthritis?

53. Rheumatism?

54. Eye disease?

55. Glaucoma?

56. Skin disease?

57. Anemia?

58. Other blood disorders?

59. STI?

60. Hormone Deficiency?

61. Kidney disease?

62. Bladder disease?

63. Thyroid disease?

64. Adrenal disease?

65. Liver Disease?

D. Do you have or have you had?

Please select YES or NO to the following:

66.Surgeries (list below in section H)?

67. Blood Transfusions?

68. Artificial Joint?

69. Contact Lenses?

70. Psychiatric Care?

71. Radiation Treatments?

72. Chemotherapy?

73. Prosthetic heart valve?

74. Pacemaker?

75. Currently taking Birth Control Pills?

76. Currently Pregnant or nursing?

E. Do you take or have you taken?

Please select YES or NO to the following:

77.Recreational drugs?

78.Alcohol?

79.Tobacco in any forms (smoke or chew)?

80.Fen Phen diet pills or any other diet pills?

81.Osteoporosis medication?

82.Trouble getting numb?

83.Adverse reaction to local anaesthetic?

F. Do you have any allergies, if yes please list?

(Antibiotics, Latex, Medications, Etc)

Patient initials:

G. Medications or Vitamins:

H. List of Surgeries:

84. Do you have or have you had any other diseases or medical problems NOT listed on this form?

If yes, please specify:

85. Have you ever been told by a physician or dentist that you need to be pre-medicated with antibiotics prior to any dental treatment?

Name of your Former Dentist:

Last Dental Visit:

Patient Signature:

Date:

Doctor Signature:

Date:

Monday	8:00am	–	5:00pm
Tuesday	8:00am	–	7:00pm
Wednesday	8:00am	–	5:00pm
Thursday	8:00am	–	5:00pm
Friday	8:00am	–	4:00pm

Monday	8:00pm	–	5:00pm
Tuesday	8:00pm	–	5:00pm
Wednesday	8:00pm	–	5:00pm
Thursday	8:00pm	–	5:00pm
Friday	8:00pm	–	4:00pm

Medical Health History

PATIENT INFORMATION

Cornwall Dental Arts

Hours

Location