MEDICAL DENTAL HISTORY 

Patient's Name : ____________________________________

DOB : _______________________________________________

SSN : _______________________________________________

INSTRUCTIONS: To receive treatment in this office you must answer all questions on this history form. The questions asked relate directly to the safe and effective treatment you are to receive in the office-to the best of your ability, honest answers must be given. If you are unsure of the questions, unsure of your answer, or whether the questions relate to your medical condition, you are to discuss the matter with the doctor. Some of the questions may not relate to your medical condition; in the event you are to write "N/A" (not applicable) in the space provided. All questions must be answered. To properly evaluate your current health status it may be necessary for the dentist to contact your physician. Included on this form is "Permission to Release Information."Please sign it in the presence of a member of the office staff. ALL INFORMATIONS YOU SUPPLY ON THIS FORM OR INFORMATION OBTAINED BY YOUR PHYSICIAN AND THE SUBSEQUENT INTERVIEW BY THE DENTIST WILL BE HELD IN THE STRICTEST CONFIDENCE, AND WILL NOT BE DISCLOSED WITHOUT YOUR WRITTEN PERMISSION. 


Name, address and telephone number of your physician : _____________________________

___________________________________________     ____________________________________


Date of last visit to your MD ______________ Purpose of visit ______________________ 
 
Do you suffer from any disability? ___________  If yes, describe ___________________
  
PLEASE CHECK EACH OF THE FOLLOWING: YES OR NO 


YES NO        					YES NO 

Rheumatic Fever     				Cancer-Radiation/Chemotherapy 

Joint Replacement (hip, knee etc) 	 	(Please circle type of treatment) 

Heart Murmur 					Epilepsy/Seizures 

Surgery (type___ YR___ ) 				Fainting/Nervousness