Medical History
Physician___________________________________________Date of Last Visit_____________________
Please list all medications you are currently taking:_______________________________________________
_____________________________________________________________________________________
Allergies:______________________________________________________________________________
(Women) Are you pregnant?__________ Nursing?_________ Taking birth control pills?__________________
Do you have a history of the following: (Please check if yes)
	AIDS	Epilepsy	Psychiatric Care
	Anemia	Fainting	Radiation Treatment
	Arthritis, Rheumatism	Glaucoma	Respiratory Disease
	Artificial Heart Valves	Headaches	Rheumatic Fever
	Artificial Joints	Heart Murmur	Scarlet Fever
	Asthma	Heart Problems	Shortness of Breath
	Back Problems	Hemophilia	Skin Rash
	Blood Disease	Hepatitis	Stroke
	Cancer	High Blood Pressure	Swelling of Feet or Ankles
	Chemical Dependency	HIV Positive	Thyroid Problems
	Chemotherapy	Jaw Pain	Tobacco Habit
	Circulatory Problems	Kidney Disease	Tonsillitis
	Cortisone Treatments	Liver Disease	Tuberculosis
	Cough, Persistent	Mitral Valve Prolapse	Ulcer
	Cough up blood	Nervous Problems	Venereal Disease
	Diabetes	Pacemaker
Authorization
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practicioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
X________________________________________________________________________________________
	SIGNATURE OF PATIENT (Or parent if a minor)		DATE

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