Confidential Medical History
Are you being treated for any medical condition at the present, or have you been treated within the past year?
Why are/were you being treated?
When was your last medical checkup?
Has there been any changes in your general health in the past year?
Please explain any changes in your general health.
Are you taking any medications, non-prescription drugs, or herbal supplements of any kind?
Please list any medications, non-prescription drugs, or herbal supplements.
Do you have any allergies?
Please list any allergies using the categories below:
Other (e.g. hayfever, foods, etc)
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Please explain/describe any peculiar or adverse reactions to any medicines or injections.
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
When was your surgery?
Do you have a prosthetic or artificial joint?
When was your surgery?
Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
Have you ever had hepatitis, jaundice, or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illness or operations?
Please explain why you were hospitalized.
Do you have or have you ever had any of the following? Please check all that apply.
Are there any conditions or diseases not listed above that you have or have had?
What conditions or diseases not listed above do you have or have had?
Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, heart disease, etc)
Please list any diseases or medical problems that run in your family.
Do you smoke or chew tobacco products or marijuana?
How long have you been smoking or chewing tobacco products or marijuana?
How much tobacco products or marijuana to you smoke or chew per day?
How long have you been vaping?
How much do you vape per day?
Are you nervous during dental treatment?