Medical History Form

Patient's Name

Age

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

No To These

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

No To These

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

No To These

Snoring/Sleep Apnea
Severe/Frequent Headaches
Psychiatric Problems
Ulcers

No To These

Diabetes
Thyroid Problems
Glaucoma
Cancer

No To These

Chemotherapy
Radiation Therapy
Lyme Disease
Emphysema

No To These

Tuberculosis
Asthma
Allergies or Hives
Sinus Problems

No To These

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

No To These

Venereal Disease
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia

No To These

Anemia
Sickle Cell Disease
Bruise Easily
Epilepsy or Seizures

No To These

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

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

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

Misc/Other Questions

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

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.