First Name: Last Name: Middle Initial:

Are you currently under the care of a physician? Yes No

If yes, for what conditions?

Are you taking any prescription or over the counter medications? Yes No

If yes, Please list:

Do you smoke? Yes No

Women

Are you pregnant? Yes No

Are you nursing? Yes No

Taking birth control pills? Yes No

Do you have any drug allergies? Yes No

If yes, please list:

Adverse reactions to any drugs? Yes No

If yes, explain:

Are you allergic to any of the following?

Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other

If yes, please explain:

Do you currently, or have you ever had any of the following? (Check boxes that apply)

AIDS/HIV Positive Cortisone Medicine Hemophilia Renal Dialysis Alzheimer's Disease Diabetes Hepatitis A Rheumatic Fever Anaphylaxis Drug Addiction Hepatitis B or C Rheumatism Anemia Easily Winded Herpes Scarlet Fever Angina Emphysema High Blood Pressure Shingles Arthritis/Gout Epilepsy or Seizures Hives or Rash Sickle Cell Disease Artificial Heart Valve Excessive Bleeding Hypoglycemia Sinus Trouble Artificial Joint Excessive Thirst Irregular Heartbeat Spina Bifida Asthma Fainting Spells/Dizziness Kidney Problems Stomach/Intestinal Disease Blood Disease Frequent Cough Leukemia Stroke Blood Transfusion Frequent Diarrhea Liver Disease Swelling of Limbs Breathing Problem Frequent Headaches Low Blood Pressure Thyroid Disease Bruise Easily Genital Herpes Lung Disease Tonsillitis Cancer Glaucoma Mitral Valve Prolapse Tuberculosis Chemotherapy Hay Fever Pain in Jaw Joints Tumors or Growths Chest Pains Heart Attach/ Failure Parathyroid Disease Ulcers Cold Sores/Fever Blisters Heart Murmur Psychiatric Care Venereal Disease Congenital Heart Disorder Heart Pace Maker Radiation Treatments Yellow Jaundice Convulsions Heart Trouble/Disease Recent Weight Loss

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You can also download and print this form to bring with you to your appointment.
Patient Health History (PDF)