Patient Medical History

Dentist Southfield

Patient Name

Your Email (required)

Birth Date


Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now? YesNo
If yes, who is your physician:

Have you ever been hospitalized or had a major operation? YesNo
If yes, please explain:

Have you ever had a serious head or neck injury? YesNo
If yes, please explain:

Are you taking any medications, pills, or drugs? YesNo
If yes, please explain:

Do you take, or have you taken, Phen-Fen or Redux? YesNo
If yes, please explain:

Have you ever taken Fosamax, Boniva, Actonel, or other medications containing biophosphates? YesNo
If yes, please explain:

Are you on a special diet? YesNo

Do you use tobacco? YesNo

Women: Are you... Pregnant/Trying to get pregnantNursingTaking oral contraceptives

Are you allergic to any of the following?
AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsOther
If other, please explain:

Do you use controlled substances? YesNo
If yes, please explain:

Do you have, or have you had, any of the following?

AIDS/HIV Positive YesNo
Alzheimer's Disease YesNo
Anaphylaxis YesNo
Anemia YesNo
Angina YesNo
Arthritis/Gout YesNo
Artificial Heart Valve YesNo
Artificial Joint YesNo
Asthma YesNo
Blood Disease YesNo
Blood Transfusion YesNo
Breathing Problems YesNo
Bruise Easily YesNo
Cancer YesNo
Chemotherapy YesNo
Chest Pains YesNo
Cold Sores/Fever Blisters YesNo
Congenital Heart Disorder YesNo
Convulsions YesNo
Cortisone Medicine YesNo
Diabetes YesNo
Drug Addiction YesNo
Easily Winded YesNo
Emphysema YesNo
Epilepsy or Seizures YesNo
Excessive Bleeding YesNo
Excessive Thirst YesNo
Fainting Spells/Dizziness YesNo
Frequent Cough YesNo
Frequent Diarrhea YesNo
Frequent Headaches YesNo
Genital Herpes YesNo
Glaucoma YesNo
Hay Fever YesNo
Heart Attack/Failure YesNo
Heart Murmur YesNo
Heart Pacemaker YesNo
Heart Trouble/Disease YesNo

Hemophilia YesNo
Hepatitis A YesNo
Hepatitis B or C YesNo
Herpes YesNo
High Blood Pressure YesNo
High Cholesterol YesNo
Hives or Rash YesNo
Hypoglycemia YesNo
Irregular Heartbeat YesNo
Kidney Problems YesNo
Leukemia YesNo
Liver Disease YesNo
Low Blood Pressure YesNo
Lung Disease YesNo
Mitral Valve Prolapse YesNo
Osteoporosis YesNo
Pain in Jaw Joints YesNo
Parathyroid Disease YesNo
Psychiatric Care YesNo
Radiation Treatments YesNo
Recent Weight Loss YesNo
Renal Dialysis YesNo
Rheumatic Fever YesNo
Rheumatism YesNo
Scarlet Fever YesNo
Shingles YesNo
Sickle Cell Disease YesNo
Sinus Trouble YesNo
Spina Bifida YesNo
Stomach/Intestinal Disease YesNo
Stroke YesNo
Swelling of Limbs YesNo
Thyroid Disease YesNo
Tonsilitis YesNo
Tuberculosis YesNo
Tumors or Growths YesNo
Ulcers YesNo
Venereal Disease YesNo
Yellow Jaundice YesNo

Have you ever had any serious illness not listed? YesNo
If yes, please explain:


By entering my name in the field below, I agree that, to the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

E-Signature of Patient, Parent or Guardian: