M. Brandt Bower DDS
784 South Main Street
Hartford, WI 53027
MEDICAL HISTORY
Name_______________________________ Date____________________________
1. Are you having pain or discomfort at this time?................................Yes No
2. Are you nervous about having dentistry treatment? ………………..Yes No
3. Have you been under the care of a medical doctor or been a
patient in the hospital within the past 2 years?....................................Yes No
4. Have you taken any medications or drugs within the past 2 years?...Yes No
5. Are you allergic to any medications or drugs………………………..Yes No
6. Have you ever had any excessive bleeding, requiring treatment? … Yes No
7. Is there something you’d like to change about your smile? (Color, shape, straigtening?) Yes No
CIRCLE ANY OF THE FOLLOWING CONDITIONS WHICH YOU HAVE HAD, OR PRESENTLY
HAVE
Alcoholism Emphysema Liver Disease
Allergies
Anemia
Angina Pectoris
Arthritis
Artificial Heart Valve
Artificial Joint
Asthma
Blood Transfusion
Bruise easily
Cancer, Leukemia
Cold Sores
Congenital Heart Lesions
Cortisone Medicine
Diabetes
Drug Addiction
Epilepsy or Seizures
Fainting or dizzy spells
Genital Herpes
Glaucoma
Hay Fever
Heart Disease or Attack
Heart Failure
Heart Murmur
Heart Pacemaker
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
High Blood Pressure
Kidney Trouble
Pain in Jaw Joints
Persistent Cough
Psychiatric Treatment
Rheumatic Fever
Scarlet Fever
Sinus Trouble
Stroke
Thyroid Disease
Tuberculosis
Ulcers
Venereal Disease
X-ray ,Cobalt or
Chemotherapy
Yellow Jaundice
7. When you walk up stairs or take a walk do you ever have to stop because of pain in your chest or shortness of breath………………………………………………..Yes No
8. Do your ankles swell during the day?.............................................................Yes No
9. Do you use more than two pillows to sleep…………………………………Yes No
10. Have you lost or gained more than 10 pounds during the last year?...............Yes No
11. Do you ever wake up from sleep short of breath?..........................................Yes No
12. Are you on a special diet?...............................................................................Yes No
13. Has a medical doctor ever said you have cancer or a tumor?.........................Yes No
14. Do you have a disease or condition not listed?...............................................Yes No
15. (Women) Are you pregnant?..........................................................................Yes No
Do you have any allergies to any antibiotics? __________________________________________
TO THE BEST OF MY KNOWLEDGE, ALL OF THE PRECEDING ANSWERS ARE TRUE AND
CORRECT. IF I EVER HAVE ANY CHANGE IN MY HEALTH, OR IF MY MEDICATIONS
CHANGE, I WILL INFORM THIS OFFICE AT MY NEXT APPOINTMENT.
Date__________________________Signature__________________________________