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Patient Information
Patient Name: ___________________________________________ Date Of Birth: ___________________ CIRCLE APPROPRIATE ANSWER (Leave blank if you do not understand the question)
If NO, explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Yes No Has there been a change in your health within the last year? If YES, explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Yes No Are you being treated by a physician now? If YES, explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Name of physician _______________________________________________________________________Date of last medical examination ____________________________________________________________ HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING? (Please Check)
Describe any surgeries you have had.
__________________________________________________________________________________________________________________________________________________________________________ Yes No Have you been diagnosed with sleep apnea?Yes No Do you have a CPAP machine? Yes No If you do have a CPAP machine, are you comfortable with it? ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING? (Please Check)
Other Allergies__________________________________________________________________________________________________________________________________________________________________________ MEDICATIONS AND PRESCRIPTIONS
Please list supplements, prescription or recreational drugs you are taking__________________________________________________________________________________________________________________________________________________________________________ ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST 3 MONTHS? (Please Check)
ALL PATIENTS
Yes No Do you have or have you had any other diseases or medical problems NOT listed on this form? If YES, explain:__________________________________________________________________________________________________________________________________________________________________________ Yes No Have you ever been pre-medicated for dental treatment? If YES, explain:__________________________________________________________________________________________________________________________________________________________________________ If YES, explain:__________________________________________________________________________________________________________________________________________________________________________ WOMEN ONLY
Yes No Are you taking birth control pills? The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potential medically- compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician. I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Signature
Signature of Patient (Write Adult name here) _________________________________ Date _______________

Source: http://www.drgerkin.com/wp-content/uploads/Confidential-Health-History.pdf