Patient Medical History


( this information will remain confidential )
 
 
 
1. Are you currently in the care of a physician for any medical condition(s)?    
 
 
2. Have you ever been hospitalized and/or had major surgery?    
3. Are you taking any drugs or medication at this time? (includes cannabis)    
 
 4. Have you ever had any adverse reaction to any of the following:
  Antibiotic:      
     
     

 

5. Do you suffer from any allergies (hay fever. latex etc.)?

    
 
 
6. Do you bruise easily or have prolonged bleeding?    
 
 
9. Women:
  Are you pregnant?    
  Reached menopause?     

10. Do you have or have you ever had any of the following? Please select all appropriate boxes.  

 
 
 
 
 
 
 
  
  
  
 
 
Emphysema
Epilepsy
 
 
 
 
 

 GENERAL RELEASE

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures. 

 
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