Medical History Form


    Contact Information:

    Address Information:

    Date of Birth
    How did you find out about us?
    Employer Information
    Retired Status

    Medical Information:

    List any medicines or foods you cannot take or have had a reaction to:

    Are you under a doctor's care now?

    If so, what for?

    What medicines are you taking now?

    What for?

    Have you had heart trouble?
    High blood pressure?
    Have you gained or lost much weight recently?
    Do you bleed severely after extractions?
    Do you get short of breath easily?
    Do you faint easily?
    Check if you have or have had any of these:


    How would you best describe your present health?

    Physician's Name
    Physician's Phone Number

    Additional Notes:

    Past Procedures: