Medical History Patient Name: Last: First: M.I. Your comfort and good dental health are dependent upon and accurate knowledge of you medical well being. Many medical situations can affect or be affected by procedures or drugs used for dentistry. Therefore, please fill out the following Have you ever had any of the following conditions: Check all that apply: High Blood Pressure Rheumatic Fever Heart Murmur Bypass Surgery Artificial Heart Valve Heart Attack Angina (Chest Pain) Irregular Heart Beat Congestive Heart Failure Stroke Emphysema or Asthma Hay Fever Tuberculosis Chronic Sinusitis Breathing Problem Frequent Headaches Fainting of Dizziness Seizures or Epilepsy Mitral Valve Prolapse Phen Fen / Redux Use Cerebral Palsy Mental Retardation Alzheimer's Disease Glaucoma Ulcers Hepatitis Jaundice Kidney Disease Venereal Disease (last 24 months) Genital Herpes Canker Sores Cold Sores Chronic Diarrhea Frequent Vomiting Blood Transfusion Anemia/Leukemia/Lymphoma Hemophilia Blood Problem Bleeding or Bruising Tendency Diabetes Thyroid Disease AIDS HIV Infection Cancer/Radiotherapy/Chemotherapy Past/Present Psychiatric Treatment Alcoholism Allergies Check all that apply: Penicillin Allergy Sulfa Drug Allergy Aspirin Allergy Novocain/Xylocaine Allergy Codeine Allergy Latex Product Allergy Other Allergies Women: Are you Pregnant? Yes No (If Yes, Number of Months) Are you taking any birth control medication? Yes No Do you anticipate becoming pregnant? Yes No Dental History: Do you feel nervous about having dental treatment? Yes No Have you ever had a bad experience in a dental office? Yes No Social History: Do you use tobacco? Yes No Do you drink alcoholic beverages? Yes No How much per day? Past or present history of drugs addiction? Yes No Do you have any other conditions not already mentioned? History of Hospitalization / Surgical Procedures: Current Medications: Prescribed and over-the-counter medications taken within the last 6 months. PERMISSION FOR ROOT CANAL PROCEDURE - I, the undersigned, consent to the performing of whatever procedure may be decided upon to be necessary and advisable in the opinion of the doctor. I also understand that only the root canal treatment is to be done at this office. The permanent (outside) restoration (filling,inlay,crown,etc.) will be completed by my regular dentist. Signed:_________________________ Parental Permission_______________________ Date:___________ Use the following menu to navigate the registration site! Patient Information | Financial Information | Medical History or Click here to return to our Home Page

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