Please check any of the following which you have had or have at the present
Heart Failure
High Blood Pressure
Rheumatic Fever
Mitral Valve Prolapse
Swollen Ankles
Shortness of Breath
Persistent Cough
Sinus Trouble
X-ray or Cobalt Treatment
Cortisone or Steroid
Yellow Jaundice
Fainting or Dizzy Spells
Sickle Cell Disease
Easy or Chronic Fatigue
Swollen Glands
Blood in your stool
Blood in Urine
Heart Disease or Attack
Scarlet Fever
Heart Pacemaker
Chest Pains
Tuberculosis (TB)
Thyroid Disease
Blood Transfusion
Venereal Disease
(Syphilis, Gonorrhea)
Bruise Easily
Unexplained Gain or Loss of
Night Sweats
Kidney Trouble
Increase in Thirst
Angina Pectoris
Heart Murmur
Artificial Heart Valve
Heart Surgery
Artificial Joint
Chronic Bronchitis
Any Form of Cancer
Food Allergies
Liver Disease
Drug or Alcohol Abuse
Epilepsy or Seizures
Psychiatric Treatment
Chronic Diarrhea or
Constant or re-occurring
Frequent Infections
Frequent Vomiting
Difficulty Urinating
Frequent Urination
Do You Have Any of the Following Drug Allergies? Are you under a physicians' care? What for? _______________________________
Y N Aspirin Y N Codeine __________________________________________________________________
Y N Darvon Y N Erythromycin Have you ever been admitted to a hospital? ______________________
Y N Nitrous Oxide Y N Valium Are you taking any medications? What? _________________________
Y N Percodan Y N Penicillin __________________________________________________________________
Y N Local Anesthetic __________________________________________________________________
Y N Other __________________________________ Family Physician _____________________ Phone ( ____ ) _____-_______
Y N Have you ever had a general anesthetic?
Y N Have you ever had a bleeding problem following any type of surgery or tooth extractions?
If Yes, please explain: _________________________________________________________________________________________________
Y N Do you smoke? If Yes, How much? ______________________________________________________________________________________
Y N Do you drink alcoholic beverages?
Y N Are you Pregnant? Obstetrician _____________________________________________________________________________________
Y N Have you u ever had a drug dependency problem?
If Yes, please explain: _____________________________________________________________________________________________
Y N Do you use recreational drugs?
Y N Do you have difficulty opening your mouth?
Y N Do you have pain or noise in your jaw joints?
Y N Do you have pain in your temples or cheeks?
Y N Do you have pain chewing or yawning?
Y N Do you clinch or grind your teeth?
Y N Have you ever been treated for TMJ problems?
Approximate date of last medical exam? _____/_____/_____
Is there any other medical or dental information we should know about? _______________________________________________________________
Notice to Patients Taking Oral Contraceptives (Birth Control Pills)
The effectiveness of birth control pills can be reduced by taking or using some drugs used in dental surgery. These drugs include pain
medication, antibiotics and drugs used in sedation and anesthesia.
This is to inform you of this possibility and when indicated, other forms of birth control should be used during the month that oral surgery is
performed. __________ (please initial)
To the best of my knowledge all of the preceding answers are true and correct. If I ever have any change in my health, or if my medicines change, I will
inform the doctor at the next appointment without fail.
Date ____/____/_______ Signature of Patient, Parent or Guardian __________________________________________________________________
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