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Microsoft word - patient med history 2 pages.doc

PATIENT MEDICAL HISTORY

Patient’s Name__________________________________________________________ Date_______________________________________

Physician’s Name____________________________________ Clinic Name _______________________ Phone________________________
Date of Last Medical Examination_______________________________________________________________________________________

1. Are you under medical treatment now? Yes
If yes, what is the condition? _____________________________________________________________________________
2. Have you ever been hospitalized for any surgical
operations or serious illness? Yes
If yes, please explain_____________________________________________________________________________________
3
. Have you ever had excessive bleeding following an injury? Yes No 4. Do you smoke or use tobacco products? Yes No
If yes, how often? _______________________________
5. Are you allergic to or have you had any reaction to the following: 6. Women Only a) Are you pregnant or think
Local Anesthetic (Novocaine) Yes No you may be pregnant? Yes No
Penicillin or Other Antibiotics Yes No b) Are you nursing? Yes No
Sulfa Drugs
c) Are you taking contraceptives? Yes No Other (please identify)________________________________________

7. Check any of the following which you have had or have at present
:

____Blood Transfusion (Date :_________) ____Heart Attack (Date :________) ____ None Apply

8. Check any over the counter Herbal or Natural Supplements 9 . Are you taking or have you ever taken
you are taking: Bisphosphonates for osteoporosis & cancer such as:

____Ginkgo Biloba _____Fosamax _____ Aredia ____Motrin/Advil (Ibuprophen) _____ Actonel _____ Skelid ____St. Johns Wort _____ Zometa _____ Didronel
*Is Pre-medication Necessary? Yes No If Yes, why? _________________________________________________________________
Please List Any Other Medical Information_______________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Patient Signature_____________________________________________________________________Date____________________________


Patient Name ___________________________________________________________ Date _____________________________________
Please List Any Medications, Including “Over The Counter”, You Are Currently Taking:

____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Patient Signature ________________________________________________________ Date ________________________________________
***************************************** Below For Office Staff Only ****************************************************
DATE

SIGNATURE /
CHANGE IN HEALTH OR MEDICATION

Source: http://swbothelldentistry.com/pdfs/medicalhistory.pdf

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