Patient Medical History Form

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Patient Medical History

Physician

Physician#

Medications you are currently taking:

Aspirin Physician

Are you allergic or had any reactions to the following?

Local Anesthetic (eg. Nococaine)

Yes
No

Penicillin/Amoxicillin

Yes
No

Ibuprofen

Yes
No

Codeine

Yes
No

Aspirin

Yes
No

Sulfa

Yes
No

Latex Rubber

Yes
No

Do your gums bleed while brushing or floss?

Yes
No

Do you feel pain in any of your teeth?

Yes
No

Do you have any sores or lumps in or near your mouth?

Yes
No

Do you grind your teeth?

Yes
No

Have you ever had any prolonged bleeding following extractions?

Yes
No

Have you had any orthodontic treatment?

Yes
No

Please indicate if you have any of the following health conditions

AIDS or HIV Infection

Yes
No

Heart Murmur

Yes
No

Arthritis

Yes
No

Hepatitis/Jaundice

Yes
No

Asthma

Yes
No

Radiation Therapy

Yes
No

Bleeding Problems

Yes
No

Mitral Valve Prolapse

Yes
No

High/Low Blood Pressure

Yes
No

Kidney Disease

Yes
No

Stroke

Yes
No

Sleep Apnea

Yes
No

Sinus Trouble

Yes
No

Tuberculosis

Yes
No

Liver Disease

Yes
No

Thyroid Problems

Yes
No

Ulcers

Yes
No

Pregnant

Yes
No

Blood Thinners

Yes
No

Do you need to take a PRE MED

Yes
No

Diabetes

Yes
No

Joint Replacement or Implant

Yes
No

Fainting/Seizures

Yes
No

Describe Surgery

Heart Disease

Yes
No

Describe Surgery

Cancer

Yes
No

Date:

Emphysema

Yes
No

Doctor:

1000, 42 Nd St, SE, Suite B
Cedar Rapids, IA 52403

Call / Text : 319-249-6970

Email: office@rapidsdental.com

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