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Medical History Form

Robert C. Doshier D.D.S. P.A.
Medical History

You may fill out and submit this form on our Web site! Or, if you have concerns about providing information via the internet, fill it out, and print it prior to an appointment. Then bring it with you to your first visit to save time when you arrive.

Patient Name:

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?
 Yes No N/A

Have you ever been hospitalized or had a major operation?
Yes No N/A

Have you ever had a serious head or neck injury?
Yes No N/A

Are you taking any medications, pills, or drugs?
Yes No N/A

If you answer yes to any of the above questions, please explain below:

Do you take, or have you taken, Phen-Fen or Redux?
Yes No N/A

Are you on a special diet?
Yes No N/A

Do you use tobacco?
Yes No N/A

Do you use controlled substances?
Yes No N/A

Women: Are you
Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin Penicillin Codeine Acrylic Metal
Latex Local Anesthetics Other (listed below)

Other allergies:

Do you have, or have you had, any of the following?

Aids/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve*
Artificial Joint*
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
 Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur*
Heart Pacemaker*
Heart Trouble/Disease

Hemophillia
Hepatitus A
Hepatitus B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse*
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever*
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice

  

Have you ever had any serious illness not listed above?
Yes No N/A

Comments:

*Condition may require medication

N/A - Not Applicable

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to Inform the dental office of any changes in medical status.

Signature of Patient, Parent, or Guardian:          
Date:

You may fill out and submit this form on our Web site! Or, if you have concerns about providing information via the internet, fill it out, and print it prior to an appointment. Then bring it with you to your first visit to save time when you arrive.



  

Robert C. Doshier, D.D.S., P.A. • 125 Sisco Street, Harrison, Arkansas 72601 • (870) 741-8551
E-mail: bdoshier@doshierdds.com • www.doshierdds.com

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