Medical Information Form
(STEP 2 OF 3 )
Correct answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate to your particular needs.

Last Name: First Name:

Why are you seeking dental treatment?

Is this for emergency care? YES NO
Are you in good health now? YES NO
Are you under the care of another doctor? YES NO
If so, what is the condition?
Have you ever been hospitalized? YES NO
If yes, explain:
Have you ever had excessive bleeding following an extraction, laceration or injury? YES NO
Women, are you pregnant? YES NO
Due date (mmddyy):
Do you use tobacco in any form? YES NO
Do you use alcoholic beverages? YES NO
Do you use recreational drugs? YES NO

Do you have or have you ever had any problems with?
  • Anemia YES NO
  • Diabetes YES NO
  • Thyroid disorder YES NO
  • Rheumatic fever YES NO
  • Hepatitis YES NO
  • Jaundice YES NO
  • Epilepsy YES NO
  • Asthma YES NO
  • Glaucoma YES NO
  • Tumors YES NO
  • Cancer YES NO
  • Radiation YES NO
  • Headaches YES NO
  • Dizziness YES NO
  • Abnormal bleeding YES NO
  • Emphysema YES NO
  • Numbness/tingling YES NO
  • Sinus problems YES NO
  • Kidney disease YES NO
  • HIV Aids or Aids-related Illness YES NO
  • Bruise easily YES NO
  • Blood pressure YES NO
  • Heart disease YES NO
  • Heart attack YES NO
  • Stroke YES NO
  • Heart valve YES NO
  • Pacemaker YES NO
  • Heart surgery YES NO
  • Arthritis YES NO
  • Allergies YES NO
  • Allergic to Penicillin YES NO
  • Allergic to Novacaine YES NO
  • Allergic to Codiene YES NO
  • Allergic to Aspirin YES NO
  • Convulsions YES NO
  • Tuberculosis YES NO
  • Ringing ears YES NO
  • Ulcers YES NO
  • HIV Positive YES NO
Have you ever had psychiartic treatment or a nervous condition? YES NO
If yes, please explain.
Are you taking any medications? YES NO
If yes, please list.

Is there any disease, condition or problem not listed above that you think we should know about?


Have you ever had any trouble with previous dental work?