Medical History Form

Thank you for selecting our oral surgical team! We strive to provide you with the best possible care. To help us meet all your surgical health care needs, please fill out this form completely. If you need any assistance or have any questions, please ask our friendly staff — we will be happy to help.

All data entered is encrypted, transmitted, and stored securely.

Patient's Name

Age

Height

Weight

Physician's Name

Dentist's Name

Have you been a patient in the hospital during the past year?
In the past two (2) years, have you had a serious illness requiring a physician’s care?

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
Heart Disease or Attack
Angina Chest Pain
Heart Murmur

None of the Above

High/Low Blood Pressure
Mitral Valve Prolapse
Heart Pacemaker
Heart Surgery

None of the Above

Rheumatic Fever
Artificial Heart Valve
Artificial Joints (hip, knee, etc.)
TMJ (jawjoint) Problems

None of the Above

Snoring/Sleep Apnea
Severe/Frequent Headaches
Psychiatric Problems
Ulcers

None of the Above

Diabetes
Thyroid Problems
Glaucoma
Cancer

None of the Above

Chemotherapy
Radiation Therapy
Lyme Disease
Emphysema

None of the Above

Tuberculosis
Asthma
Allergies or Hives
Sinus Problems

None of the Above

Hepatitis
Liver Disease
H.I.V. Positive/A.I.D.S.

None of the Above

Venereal Disease
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia

None of the Above

Anemia
Sickle Cell Disease
Bruise Easily
Epilepsy or Seizures

None of the Above

Fainting or Dizzy Spells
Drug Addiction
Have you ever taken prescription medication for weight reduction (diet pills)?

None of the Above

Have you ever taken prescription medication for osteoporosis (bisphosphonate: fosamax, zoireta, areta)?
Do you take health food supplements (ginkgo, St. Johns wort, vitamin E, ginseng)?

None of the Above


Are you sensitive or allergic to any of the following medications?

None of the Below

Penicillin
Erythromycin
Tetracycline
Sulfa
Codeine
Aspirin/Ibuprofen
Tylenol/Acetaminophen
Steroids
Latex
Local Anesthetics
Food (e.g. egg, soy)
Other

Misc/Other Questions

None of the Below

Do you smoke?

If yes, how much per day?

Do you drink alcohol?

If yes, how much per day?

Do you take recreational drugs?

If yes, how much per day?

Do you have or have you had any disease, condition or problem not listed?

If yes, please list


For Women Only

None of the Below

Are you taking birth control pills?
Are you nursing?
Are you pregnant?

If yes, what month?


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.