Medical History Form

Please fill out the form below and submit it prior to your appointment and we will have your paperwork ready and completed for you when you arrive. If you have not scheduled your appointment yet, you may use our online appointment request form or give us a call. Required fields are marked with asterisks (*).

 

Patient Information

First Name: *

Last Name: *

Do you have a personal physician?

Yes No  

Physician's Name:

Physician's Phone:

Date of last visit:

Are you currently under the care of a physician?

Yes No  

If yes, please explain:

Your current physical health is:

Excellent Good Fair Poor  

 

WOMEN ONLY - Are you currently:

Using Birth Control or Hormones

Pregnant

Nursing

 

Delivery date if pregnant:

 

Medical History

Do you currently experience:

Abnormal Bleeding

Yes No  

 

Alcohol / Drug Abuse

Yes No  

 

Anemia

Yes No  

 

Arthritis

Yes No  

 

Artificial Bones/Joints/Valves

Yes No  

 

Asthma

Yes No  

 

Blood Transfusion

Yes No  

 

Cancer / Chemotherapy

Yes No  

 

Colitis

Yes No  

 

Congenital Heart Defect

Yes No  

 

Diabetes

Yes No  

 

Difficulty Breathing

Yes No  

 

Emphysema

Yes No  

 

Epilepsy

Yes No  

 

Fainting Spells

Yes No  

 

Frequent Headaches

Yes No  

 

Glaucome

Yes No  

 

Hay Fever

Yes No  

 

Heart Attack

Yes No  

 

Heart Murmur

Yes No  

 

Heart Surgery

Yes No  

 

Hemophilia

Yes No  

 

Hepatitis

Yes No  

 

Herpes / Fever Blisters

Yes No  

 

High Blood Pressure

Yes No  

 

HIV+ / AIDS

Yes No  

 

Hospitalized for any reason

Yes No  

 

Kidney Problems

Yes No  

 

Liver Disease

Yes No  

 

Low Blood Pressure

Yes No  

 

Lupus

Yes No  

 

Mitral Valve Prolapse

Yes No  

 

Osteoporosis / Paget's Disease

Yes No  

 

Pacemaker

Yes No  

 

Psychiatric Treatment

Yes No  

 

Radiation Treatment

Yes No  

 

Rheumatic / Scarlet Fever

Yes No  

 

Seisures

Yes No  

 

Shingles

Yes No  

 

Sickle Cell Disease / Traits

Yes No  

 

Sinus Problems

Yes No  

 

Stroke

Yes No  

 

Tuberculosis (TB)

Yes No  

 

Ulcers

Yes No  

 

Venereal Disease

Yes No  

 
 

 


Please list any serious medical condition(s)that you have ever had:

Select any of the following drugs you have had allergic reactions:

 

Asprin

Codeine

 

 

Dental Anesthetics

Erythromycin

 

 

Latex

Penicillin

 

 

Tetracycline

Other

 

Please list any other drugs/materials that you are allergic to:

 

I certify the information recorded on this medical & dental form is correct. I understand it is my responsibility to notify Dental Professionals of any changes. I understand if I withhold information regarding allergies, medical conditions, medications, or supplements; I agree not to hold Dental Professionals or its employees liable in the event of death or injury.

 
 

It may take a moment to submit your information. Please wait for a confirmation message.

 

OHIOSmiles

1500 Deerpath Drive
Cambridge, OH 43725

(740) 439-2501

Opening Hours

Monday & Tuesday: 8am–4pm
Wednesday: 11am–7pm
Thursday: 8am–4pm
Friday: 7am–3pm

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