Medical History Form

Patient Name

Age

Date

Home Address

Phone

City

Soc Sec Number

What is your impression of your health?

When was your last physical examination?

PLEASE ANSWER THE FOLLOWING QUESTIONS AS ACCURATELY AS POSSIBLE

Are you presently, or have you been under the care of a physician during the past year? For what purpose?

Do you have any medical condition or medical problems? Please explain:

Are you taking any medication or drugs? What are they:

Are you allergic to any medicine or anything? Latex Rubber? What are they:

Have you had a reaction to local anesthetic or intravenous medications?

Please explain

Have you had complications following medical or dental treatment? Please explain

Do you have bleeding problems or blood diseases? Please explain:

Are you pregnant?

Which Month

Do you smoke or use tobacco?

Comments

The information that I have given on this form is the most complete, up to date medical and/or dental facts that are available. If my medical condition changes in any way I will inform Dr. Khoury before further treatment.

Patient Signature

Use your mouse cursor or the tip of your finger to sign below

Date:

Medical History Reviewed:

Dr.

Date

Followup History Reviewed:

Dr.

Date

Vital Signs

Pulse

Temp

Comments:

Patient Medical History

Patient Signature

Medical History Reviewed:

Followup History Reviewed:

Vital Signs