Patient's Name:

Patient's E-mail:

Patient's Cell:

Patient's D.O.B.

Indicate which of the following conditions apply to you presently or in the past.

	Yes	No		Yes	No
hospitalization for illness or injury			allergic/adverse reaction to aspirin
allergic/adverse reaction to antibiotics			allergic/adverse reaction to codeine
allergic/adverse reaction to local anesthetics, etc.			allergic/adverse reaction to fluoride
allergic/adverse reaction to metals (gold, etc.)			allergic/adverse reaction to latex
allergic/adverse reaction to foods			allergic/adverse reaction to other medications
advised against taking any medication			heart problems (angina, heart attack, rhythm, etc.)
heart murmur or mitral valve prolapse			rheumatic or scarlet fever
artificial heart valve or pacemaker			artificial joints
advised to take antibiotics before dental visit			high blood pressure
low blood pressure			high cholesterol
stroke			swelling of ankles, feet, or hands
anemia or other blood disorder			prolonged bleeding due to slight cut
asthma			bronchitis
tuberculosis			shortness of breath on exertion
sinus problems			kidney disease
liver disease/jaundice			hepatitis
thyroid or parathyroid disease			hormone deficiency, glandular disorders
diabetes (personal or family history)			stomach or duodenal ulcer
digestive disorders			special diet presently
recent weight, appetite or energy level change			arthritis/rheumatism
glaucoma			eye glasses/ contact lenses
earaches/ear/throat infections frequently			hearing difficulties
epilepsy or seizures			fainting or dizzy spells
headaches, severe, frequent			head/neck injuries
HIV/AIDS			viral infections, cold sores (herpes)
venereal disease			any lumps or swelling in the mouth
hives, skin rash, hay fever			cancer, leukemia, lymphoma
tumour, abnormal growth			radiation or chemotherapy
organ transplant, medical implant			emotional problems
psychiatric treatment			antidepressant medication
alcohol/drug dependency			eating disorders
malignant hyperthermia			steroid therapy
diet pill therapy			presently or in the last year treated for any illness
any change in your general health in the last year			a heavy smoker (use chewing tobacco)
FEMALE – taking birth control pills			FEMALE – pregnant (or suspect you are)
FEMALE – breast feeding			MALE – prostate disorders
CHILD – recent measles, mumps, chicken pox			CHILD – recent strep throat, tonsillitis
Do you currently have, or have had in the past, any disease, condition or problem not listed above?			Is there anything else about your health we should be made aware of?
Do you wish to speak to the Doctor privately about any problem or medical condition?

Please describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.

List any medications, non-prescription drugs or herbal supplements of any kind.

I, the undersigned, certify that I have provided an accurate and complete personal medical history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical history. Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures that may be required to determine necessary treatment. I understand that information provided from or to my medical doctor(s) or another health care provider may be necessary, and I consent to the release of this information.

I have read and agree to the above release: