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? YesNo If so, what for? What medicines are you taking now? What for? Have you had heart trouble? YesNo High blood pressure? YesNo Have you gained or lost much weight recently? YesNo Do you bleed severely after extractions? YesNo Do you get short of breath easily? YesNo Do you faint easily? YesNo Check if you have or have had any of these: Stomach TroubleRheumatic FeverKidney TroubleScarlet FeverBladder TroubleEpilepsyAsthmaCancerTuberculosisTumorDiabetesStrokePneumoniaHepatitisConvulsionsAllergiesAnemia Other: How would you best describe your present health? Physician's Name Physician's Phone Number Additional Notes: Past Procedures:
