In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you have.

NOTE: Fields marked with an asterisk (*) are required.

PATIENT INFORMATION

Title:

Patient Name:*

CONTACT INFORMATION
Emergency Contact:*
Phone Number:*
Family Doctor:
Phone Number:

Are you presently being treated for any medical condition at the present or within the past year?

 Yes   No 
If yes, please explain why:

Was your last medical checkup within the past year?

 Yes   No 

Has there been any change in your general health in the past year?

 Yes   No 

Are you currently taking any medications or non-prescription drugs of any kind?

 Yes   No 
If yes, please list:

Have you ever been warned against using any other medications?

 Yes   No 
If yes, please list:

Have you ever taken prolonged medical or non-medical drugs?

 Yes   No 
If yes, please list:

Do you suffer from any allergies (hay fever, latex/rubber, etc)?

 Yes   No 
If yes, please list:

Allergies: Have you ever had a reaction to any of the following?*

Penicillin
Sulfonamide
Asprin
Barbiturates (sleeping pills)
Codeine
Darvon
Local Anesthetic (Freezing)
General Anesthetic
No Drug Allergies
Other (please specifiy below)

Do you or did you smoke?

 Yes   No 
If yes, for how long?

Do you drink alcoholic beverages on a regular basis?

 Yes   No 

Do you use recreational drugs? (e.g. cocain or amphetamines)

 Yes   No 

(For women only) Are you pregnant?

 Yes   No 
If yes, when is your due date?

Do you bruise easily or have prolonged bleeding?

 Yes   No 

Have you ever fainted, had shortness of breath, or chest pains?

 Yes   No 

Are you anxious during dental treatments? (Please indicate by marking the scale)

 Not at all   1   2   3   4   5   Very anxious 

If you are nervous, would you like us to consider additional techniques along with "freezing" to help you?

 Yes   No 

Have you ever had any serious trouble with any previous dental treatment?

 Yes   No 
If yes, please describe:

Do you have or have you had any of the following conditions. Please check all that apply:*

Aids
Anemia
Angina pectoris
Anorexia nervosa
Artificial Heart Valve
Arthiritis/rheumatism
Artificial joints (hips, knees)
Asthma
Blood Disorders
Bronchitis
Bulimia
Cancer
Circulation Problems
Congenital Heart Lesions
Cortisone/steroid
Diabetes
Drug/alcohol dependence
Emphysema
Epilepsy
Glandular Disorders
Glaucoma
Head/Neck Injuries
Heart Disease/Attack
Heart Murmur
Heart Pacemaker/surgery
Heart Rhythm Disorder
Hepatitis A/B/C
Herpes
High/Low Blood Pressure
HIV Positive
Hodgkin's Disease
Hyper (Hypo) Glycemia
Hypertension
Jaundice
Kidney Disease
Liver Disease
Leukemia
Lung Disease
Malignant Hypothermia
Mental/Nervous Disorder
Mitral Valve Prolapse
Organ Transplant/Implant
Psychiatric Disorders
Radiation/Chemotherapy
Rheumatic/Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Stomach/Intestinal Problems
Stroke
Thyroid Disease
Tuberculosis
Ulcers
Venereal Disease
Other
None of the above

Is there anything else we should know about your health?

CONSENT
 I acknowledge that the information given to me is true to the best of my knowledge and that the questions have been reviewed with me. Should there be any changes to my present health status in the future, I will advise Clinton Dental. I have been informed that my physician may be contacted by letter, email, fax, or telephone in order to complete details of my medical history. I hereby consent to my physician providing Clinton Dental with any information in this regard which may ensure safe dental treatment. Finally, I hereby acknowledge that dental treatment may be delayed until all medical information required by Clinton Dental is received.


Patient Name*:
Date*:
Patient Initials*: