Medical History Form

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Patient Email: *

Home phone: *

Work phone:

Cell phone:

Date of birth: *

Emergency Contact Name:

Emergency Contact Phone:

Primary Medical Doctor:

When was your last physical?

Date of last dental visit(if not here):

Clinic / Doctor:

Emergency Contact/Phone Number:

Preferred Pharmacy:

Diabetes

High blood pressure

MS, stroke, seizures

High levels of cholesterol

Asthma or breathing disorders

Allergy - Seasonal

Environmental

Sinus conditions

Weight loss / gain

Skin - Rosacea

Cancer

Headache

Communicable diseases

HIV

Chlamydia

Thyroid trouble

Rheumatoid arthritis

Shingles / herpes zoster

Sleep disorders

Ulcers or kidney disorders

Are you pregnant?

Do you have a history of cancer?

If so, what kind of cancer?

Please list any medications and supplements you are currently taking:

Please list any known medications you have had an allergic reaction to:

Do you live alone?

Do you smoke?

If so, number of packs/day:

Do you consume alcohol?

If so, number of drinks/day:

Occupation (if any):

Employer (if any):

Recreational activities: