Medical HistoryPatient Physician Date Of Last Visit Please list all medications you are currently taking with dosage: List all allergies: Are you pregnant? YesNoNursing? YesNoTaking birth control pills? YesNoIndicate which of the following you have had, or have at present? (Check all that apply).AIDSCirculatory ProblemsHepatitisScarlet FeverAllergies or HivesCold SoresHigh Blood PressureShortness of BreathAnemiaCortisone TreatmentsHIV PositiveSinus ProblemsAnxiety ProblmesCough, Persistent Jaw PainSkin RashArtificial Heart ValvesDiabetesLatex SensitivitySwelling of Feet/AnklesArtificial JointsEpilepsyLiver DiseaseThyroid ProblemsAsthmaFaintingMitral Valve ProlapseTobacco HabitBack ProblemsGlaucomaNeurological ProblemsTonsillitisBlood DiseaseHeadachesPacemakerTuberculosisCancerHeart MurmurPsychiatric CareUlcersChemical DependencyHeart problemsRadiation TreatmentVenereal diseaseChemotherapyHemophiliaRheumatic Fever Other: Please describe any positive responses from the list above: Do you smoke? YesNo Describe Do you use alcohol? YesNo Describe Do you use recreational drugs? YesNo Describe Have you had surgery or been hospitalized in the last 5 years? YesNo Describe Dentist’s Signature Date: History Review History Review History Review History Review
