Medical History Form Patient's Name Age Height Weight BMI Gender Male Female Physician's Name Dentist's Name Preferred Pharmacy for Rx: Location: Have you been a patient in the hospital during the past year? Yes No In the past two (2) years, have you had a serious illness requiring a physician’s care? Yes No List medications/drugs you are taking List prior operations/hospitalizations Indicate which of the following you have had or have at present. Circle ”yes” or ”no” to each item Stroke Yes No Heart Disease or Attack Yes No Angina Chest Pain Yes No Heart Murmur Yes No None of the Above High/Low Blood Pressure Yes No Mitral Valve Prolapse Yes No Heart Pacemaker Yes No Heart Surgery Yes No None of the Above Rheumatic Fever Yes No Artificial Heart Valve Yes No Artificial Joints (hip, knee, etc.) Yes No TMJ (jawjoint) Problems Yes No None of the Above Snoring/Sleep Apnea Yes No Severe/Frequent Headaches Yes No Psychiatric Problems Yes No Ulcers Yes No None of the Above Diabetes Yes No Thyroid Problems Yes No Glaucoma Yes No Cancer Yes No None of the Above Chemotherapy Yes No Radiation Therapy Yes No Lyme Disease Yes No Emphysema Yes No None of the Above Tuberculosis Yes No Asthma Yes No Allergies or Hives Yes No Sinus Problems Yes No None of the Above Hepatitis A B C D No Liver Disease Yes No H.I.V. Positive/A.I.D.S. Yes No None of the Above Venereal Disease Yes No Cold Sores/Fever Blisters Yes No Blood Transfusion Yes No Hemophilia Yes No None of the Above Anemia Yes No Sickle Cell Disease Yes No Bruise Easily Yes No Epilepsy or Seizures Yes No None of the Above Fainting or Dizzy Spells Yes No Drug Addiction Yes No Have you ever taken prescription medication for weight reduction (diet pills)? Yes No None of the Above Have you ever taken prescription medication for osteoporosis (bisphosphonate: fosamax, zoireta, areta)? Yes No Do you take health food supplements (ginkgo, St. Johns wort, vitamin E, ginseng)? Yes No None of the Above Are you sensitive or allergic to any of the following medications? None of the Below Penicillin Yes No Erythromycin Yes No Tetracycline Yes No Sulfa Yes No Codeine Yes No Aspirin/Ibuprofen Yes No Tylenol/Acetaminophen Yes No Steroids Yes No Latex Yes No Local Anesthetics Yes No Food (e.g. egg, soy) Yes No Other Misc/Other Questions None of the Below Do you smoke? Yes No If yes, how much per day? Do you drink alcohol? Yes No If yes, how much per day? Do you take recreational drugs? Yes No If yes, how much per day? Do you have or have you had any disease, condition or problem not listed? Yes No If yes, please list For Women Only None of the Below Are you taking birth control pills? Yes No Are you nursing? Yes No Are you pregnant? Yes No If yes, what month? I understand the above information is necessary to provide safe surgical treatment. I have answered all questions truthfully and to the best of my knowledge. Signature of patient or responsible party (Type Full Name): Contact Us If you have questions or concerns, or wish to speak with one of our oral/maxillofacial specialists, then please contact our staff at Santa Rosa Oral Surgery, or set up an appointment by clicking here.