Medical History

Patient Name: ___________________________________ DOB: ____________ Today's Date: ____________

********************************************************************************************
Yes No Are you currently in the care of a Physician? If Yes Please Describe: ___________________________
____________________________________________________________________________________
Yes No Have you been advised by a physician of the need for any type of surgery, Pre-Medication or treatment?
____________________________________________________________________________________
Yes No Have you had any surgical operations of any kind? Please describe: _____________________________
____________________________________________________________________________________
********************************************************************************************
Do you have or have had or have you been treated for any of the following?
Yes No Heart Disease/Condition Yes No Thyroid Disease
Yes No Angina/Chest Pain Yes No Auto Immune Disease
Yes No Artificial Heart Valve Yes No Arthritis
Yes No High Blood Pressure Yes No Rheumatism
Yes No Heart Attack Yes No Stomach Ulcers/Colitis
Yes No Pace Maker Yes No GERD/Acid Reflux
Yes No Stroke Yes No Bleeding Disorder
Yes No Kidney Disorder Yes No Anemia/Sickle Cell Disease
Yes No Diabetes Yes No Hemophilia
Yes No Glaucoma Yes No Blood Transfusion
Yes No Emphysema/Lung Disease Yes No Chronic Diarrhea
Yes No Shortness of Breath Yes No Sinus/Nasal Problems
Yes No Asthma Yes No Psychiatric Treatment
Yes No Tuberculosis Yes No Chemical Dependency
Yes No Liver Disease/Jaundice Yes No Anorexia/Bulimia
Yes No Hepatitis Yes No Hypothermia
Yes No Hip or Joint Replacement Yes No HIV/AIDS
Yes No Epilepsy/Seizures/Convulsions Yes No Herpes Simplex
Yes No Chemotherapy Yes No Venereal Disease
Yes No Radiation Therapy: Head, Neck, Jaw Yes No TMJ/Clenching/Grinding
Yes No Cancer Yes No Tobacco Use;
Yes No Fainting/Dizzy Spells Freq.:___________________
********************************************************************************************
Yes No Have you ever taken Bisphosphonate Drug for Osteoporosis or treatment for Cancer? If yes please
describe: ____________________________________________________________________________________
Yes No Women: Are you pregnant? If yes, Due Date: ______________ Are you breastfeeding? Yes No
Yes No Allergic Reactions (e.i. latex, food, medications, anesthetics etc...) Please List: ____________________
____________________________________________________________________________________________
Yes No Are you currently taking any Prescribed Medications: If yes please list: _________________________
____________________________________________________________________________________________
Yes No Are you currently taking any Over-the-Counter Medications: If yes please list: __________________
Yes No Any Conditions not Mentioned prior we should be aware of: If yes please explain: _________________
____________________________________________________________________________________________
Yes No Do you wish to speak to the doctor Privately about anything?

I certify the above to be true and correct to the best of my knowledge. I will notify the office immediately of
any changes.

Patient/ Legal Guardian Signature: _______________________________ Date: ________________