Medical History Form Name * First Name Last Name Date of Birth * MM DD YYYY Email Address * Mobile Phone Number * (###) ### #### Name of Medical Doctor City/State Emergency Contact Phone Number (###) ### #### Relationship List all medications that you are now taking Are you allergic to any of the following? Anesthetic Aspirin Codeine Ibuprofen Iodine Latex Penicillin Sulfa Do you have any of the following medical conditions? Asthma Bleeding Problems Cancer Diabetes Heart Murmur Heart Trouble High Blood Pressure Joint Replacement Kidney Disease Liver Disease Pregnancy Psychiatric Treatment Sinus Trouble Stroke Ulcers Rheumatic Fever Tobacco use? If so, what kind and how much? Unusual reaction to dental injections? Reason for today's visit Are you in pain? For New Patients Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old? Do you have BiteWing x-rays that are less than 1 year old? Name of former dentist City/State Date of last cleaning and exam Signature * Please Type Your Full Name Please review to ensure the details are correct before completion. Thank you!