Mountain Springs Advanced Dental

Medical History
Patient Name *

First Name Last Name
Are you under a physicians care?

Yes No
Who is your general physician?
Have you ever been hospitalized or had a major operation?

Yes No
Please Explain
Have you ever had a serious injury to your head or neck?

Yes No
Please Explain
Are you on a special diet?

Yes No
Please list any medications or supplements you are taking
Please list any allergies to medications or substances
FOR WOMEN: Please check

Pregnant/Trying to get pregnant Nursing Taking contraceptives
Do you now have or have you ever had any of the following?

Heart murmur or defect Emphysema Kidney disease Angina chest pain COPD Dialysis Heart Attack Tuberculosis Thyroid disease Congenital heart disorder Asthma Parathyroid disease Mitral Valve Prolapse Seasonal Allergies Arthritis Scarlet Fever Cancer Artificial joint Artificial Heart Valve Tumors/growths Cortisone Medication Coronary shunts or stints Radiation Treatment Stroke Pacemaker Chemotherapy Epilepsy/seizures Bacterial Endocarditis Osteoporosis Fainting/dizziness Anemia blood disorder Stomach/intestinal disease Psychiatric care Bruise easily Ulcers Alzheimer's disease High blood pressure Low blood pressure Recent weight loss Sexually transmitted disease Blood disorder Liver disease Cold sores Leukemia Hepatitis A Hepatitis B Hepatitis C HIV/AIDS Blood transfusion Diabetes Drug/alcohol addiction Swelling of limbs Hypoglycemia Gout Lung disease Excessive thirst Allergies Pulmonary shunt Night sweats Hives/rash Breathing problem Sleep apnea Cochlear implants Frequent cough Dental premedication
Please explain if you have any of the conditions above
Patient Signature (Parent or Guardian if minor) *

Clear
Date

Month Day Year
Date
Please verify that you are human *
Should be Empty:

Medical History