Kirksvilledental.com

Medical History
Patient’s Name ______________________________________________________________________________Physician’s Name & Phone________________________________________ Date of Last Physical____________Have you ever had any of the following? (check boxes that apply)□ Heart Problems In the past, have you been required to take antibiotics prior to dental treatment for a reason other than infection? □ Yes □ NoIf so, for what condition?______________________________________________________________________Do you have any drug allergies or have you ever had an adverse reaction to any medication? □ Yes □ NoIf so, what?_________________________________________________________________________________Have you ever responded adversely to medical or dental treatment? □ Yes □ No If so, what?_________________________________________________________________________________Have you ever or are you taking Osteoporosis or cancer medication? □ Yes □ NoIf so, for what? ______________________________________________________________________________Have you ever or are you taking an oral or IV Bisphosphonate? (ie. Actonel, Boniva, Fosamax, Didronel) □ Yes □ No If so, what?_________________________________________________________________________________Are you under the care of a physician? □ Yes □ NoIf so, for what? ______________________________________________________________________________Are you taking any medications at this time? Please list name and dosage of each. Please use additional sheet if needed.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(Women) Do you suspect that you are pregnant? □ Yes □ No Are you nursing? □ Yes □ NoIs there anything else we should know about your medical history? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Signature ______________________________________________________ Date_________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ess ________________________________________________________________________ t _______________________________________________________________________ tion Number_____________________________________ Gr s SSN _________________________________________ ___________________________________________________ ___________________________________________ ess _______________________________________________________________________ t _______________________________________________________________________ tion Number_____________________________________ Gr s SSN _________________________________________ ___________________________________________________ y_______________________________________ Occupa ess___________________________________ City_______________ St t?_____________________________________________________________ ou?_________________________________________ e of Birth __________________ □ Single □ Married □ Widow tion and Medic

Source: http://www.kirksvilledental.com/docs/Patients%20Registration%20and%20Medical%20History.pdf