MEDIC
ALERT
ALLERGIES
MEDICAL HISTORY
MEDICATIONS
HEALTH COND.
PHYSICAL
FOR
The following information is required by the dentist to assist in proper diagnosis and treatment.
ALL INFORMATION IS CONFIDENTIAL.
Don’t Know
Yes /Maybe No
Know NONO
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3. Have you had a medical examination in the past year? ………………………………………………………………………………………………………………………
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4. Do you use any prescription or non-prescription medicine regularly? ……………………………………………………………………………………………………
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5. Do you have any allergic condition: i.e. asthma, hay fever, skin rash, food, drug, latex or acrylic allergies? …………………………………………..
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6. Do any allergic reactions result in headache, shortness of breath, chest constriction, nausea? ……………………………………………………….………
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7. Have you been hospitalized in the last five years? ……………………………………………………………………………………………………………………………
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8. Have you ever experienced any unusual reaction to any of the following? (Please circle) ………………………………………………………………………
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1. Have you ever had a serious illness requiring hospitalization or extensive medical care? ………………………………………………………………………….
Specify _____________________________________________________________________________________________________________
2. Are you presently under the care of a physician? …………………………………………………………………………………………………………………………..……
If so explain _________________________________________________________________________________________________________
Specify _____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Specify _____________________________________________________________________________________________________________
Local anaesthesia (freezing), aspirin, penicillin, iodine, sulfonamide, barbiturates (sleeping pills) or any other medicine? If so, explain:
___________________________________________________________________________________________________________________
9. Have you been warned against taking any drug or medication? …………………………………………………………………………………………………………
10. Do you have or have you ever had any of the following? (please check) ……………………………………………………………………………………………
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Heart murmur or mitral valve prolapse
Stomach/Intestinal problems
Joint replacement (hip, knee, etc.)
Mental or nervous disorder
High/low blood pressure
Hyper (hypo) glycemia
Epilepsy or seizures
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Malignant hyperthermia
Drug/alcohol addiction
Any lung disease
Thyroid disease
Arthritis or rheumatism
Scarlet or rheumatic fever
Cortisone/Steroid therapy
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Positive testing for HIV virus
AIDS
Diabetes
Tuberculosis
Stroke
Jaundice
Herpes
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Heart attack
Cold sores
Cancer
Kidney disease
Sinus trouble
Liver disease
Hepatitis A/B/C
 Other…
11. Do you bruise easily or bleed abnormally? ………………………………………………………………………………………………………………………………………
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12. Do you have any blood disorders such as anemia (thin blood), thalassaemia (major, minor)? ………………………………………………………………
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13. Have you had radiation treatment or chemotherapy? ………………………………………………………………………………………………………………………
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14. Have you ever had any injury, surgery or x-ray therapy to your face or jaws? ……………………………………………………………………………………
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15. Do you have frequent severe headaches? ………………………………………………………………………………………………………………………………………
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16. Do you have frequent earaches, ear/throat infections or any hearing difficulties? ………………………………………………………………………………
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17. Are you on a special diet? ………………………………………………………………………………………………………………………………………………………………
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18. Have you ever fainted? …………………………………………………………………………………………………………………………………………………………………
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19. Do you ever experience shortness of breath or chest pain when walking or climbing stairs? ………………………………………………………………
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20. Have you had any organ transplants or medical implants? ………………………………………………………………………………………………………………..
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21. Do you have any disease, condition or problem that you think the doctor should know about? …………………………………………………………….
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If so, explain ________________________________________________________________________________________________________
If so, explain ________________________________________________________________________________________________________
If so, explain ________________________________________________________________________________________________________
22. Is there anything about yourself that we should be made aware of? ………………………………………………………………………………………………….
If so, explain ________________________________________________________________________________________________________
Don’t Know
Yes /Maybe No
23. Have you ever taken medication for osteoporosis (low bone calcium)? ………………………………………………………………………………………………
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If so, for how long? ______________ When was it discontinued? _________________________
24. WOMEN ONLY
Are you pregnant?
If so, which month are you in? ……………………………………………………………………………………
Are you taking any form of birth control? ………………………………………………………………………………………………………………
To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall
inform the Dentist and staff at the next appointment without fail.
X ___________________________________________________________________________________ Date __________________________
Patient signature (Parent or Guardian)
History Review and Significant Findings _____________________________________________________________________________________
______________________________________________________________________________________________________________________
Medical Updates
I have read my Medical History dated ___________________________ and confirm that it adequately states past and present conditions.
Date
Exceptions
Patient’s Signature
Reviewed by
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