Medical History Questionnaire
Email *
Column 1
Row 1
Clear selection
Phone:
Today's Date *
MM
/
DD
/
YYYY
Title *
Required
Name *
Address *
D.O.B (Month/Day/Year) *
MM
/
DD
/
YYYY
EMAIL ADDRESS:
IN CASE OF EMERGENCY, WE SHOULD NOTIFY: *Name, Relationship, Phone: *
Family Doctor *Name, Phone or Address: *
Medical history: *
Yes
No
Abnormal bleeding
AIDS or HIV infection
Alcohol dependence
Anemia
Arthritis
Artificial heart valve
Stroke
Artificial joints (hips/knees)
Asthma
Blood disorders
Bronchitis
Cancer
Chemotherapy
Congenital heart lesion
Cortisone/steroid
Diabetes
Drug dependence
Emphysema
Epilepsy/ Seizures
Fainting/dizzy spells
Gastrointestinal disease
Glaucoma
Head/Neck injuries
Heart disease/attack
Heart murmur
Heart rhythm disorder
Heart pacemaker
Hepatitis A/B/C
Herpes
High/low blood pressure
Hodgkin's disease
Jaundice
Kidney disease
Leukemia
Liver disease
Lung disease
Mental/nervous disorder
Mitral valve prolapse
Osteoporosis
Psychiatric disorder
Rheumatic/Scarlet fever
Severe headaches/migraines
Severe/rapid weight loss
Sexually transmitted disease
Sickle cell anemia
Sinus trouble
Sleep disorder
Thyroid disease
Tuberculosis
Ulcers
Venereal disease
Do you currently have, or have had in the past, any disease, condition or problem not listed above?
Is there anything else about your health we should be made aware of?
Do you wish to speak to the Doctor privately about any problem or medical condition?
Are you taking any medications, non-prescription drugs or herbal supplement any kind? If yes, please list with the dosage
Have you ever had a peculiar or adverse reaction to any of the following medicines or injections? *
Yes
No
Antibiotics- Penicillin
Analgesic- Aspirin
Barbiturates (sleeping pills)
Local anesthetic (freezing)
Sulfonamides
Davron
Nitrous oxide or any other medication:
Office Policies: A service charge of 4% per month may be charged to accounts exceeding 30 days. There will be a monetary charge for appointments cancelled without at least 48 hours advance notice from the time of the scheduled appointment. We cannot guarantee appointments for patients who arrive more than 15 minutes late of their scheduled appointment.
General Release (Print Name) I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I give my permission to telephone or email me to discuss matters related to this form. I have had the opportunity to ask questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. *
Print Name: To the best of your knowledge, the above information is correct: *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms