Medical History

Are you Allergic to any of the following?

Do you have or have you experienced any of the following?

Acid Reflux
Drug Abuse
Memory Loss
Alcohol Abuse
Emphysema
Mitral Valve Prolapse
Arthritis
Epilepsy
Occlusal Appliance
Heart
Glaucoma
Psychiatric Care
Asthma
Headaches
Radiation Treatment
Blood Transfusion
Heart Murmur
Rheumatic Fever
Chemotherapy
Heart Surgery
Sinus Problems
Congenital Heart Defect
Hepatitis Type
Snoring
Depression
HIV/AIDS
Stroke
Diabetes
High Blood Pressure
Thyroid Problems
Anxiety
Hearing Impaired
Tuberculosis (TB)
Kidney Problems
Ulcers
Lever Disease
Vertigo
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.
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Patient/Guardian/Parent Signature