MEDICAL HISTORY Patient name____________________________________ Have you been under the care of a medical doctor during the past 2 years? ___yes ___no If yes, for what condition?___________________________________________________ Medical doctor’s name and phone # ___________________________________________ Have you been hospitalized during the past 5 years?______________________________ Do you take any medications on a regular basis? ___yes ___no If yes, please list.___________________________________________________________ Have you ever taken prescription medications for weight loss such as Fen-Phen, Pondimen or Redux? ___yes____no If yes, have you had a medical exam/echocardiogram to rule out cardiac problems?________ Are you allergic to any medications or substances? ____yes____no If yes, please list._____________________________________________________________ If you have an active heart murmur, mitral valve prolapse, or any artificial joints or implants, you must be PREMEDICATED with antibiotics prior to any dental treatment. Please circle if you have had or do have at present any of the following conditions: Heart Problems(attack,disease,surgery)                        Ulcers Chest Pain                                                                     Diabetes Heart Murmur                                                                 Thyroid Problems High Blood Pressure                                                      Glaucoma Mitral Valve Prolapse                                                     Emphysema Artificial Heart Valve                                                       Chronic Cough Pacemaker                                                                    Tuberculosis Rheumatic Fever                                                           Asthma Arthritis                                                                          Hay Fever Swollen Ankles                                                               Latex Sensitivity Stroke                                                                            Sinus Problems Artificial Joints/Implants                                                  Radiation/Chemotherapy Kidney Disease                                                             Tumors Hepatitis                                                                        AIDS/HIV Cold Sores/Fever Blisters                                             Blood Transfusion Anemia                                                                          Liver Disease Seizures/Epilepsy                                                          Jaundice                 Neurological Disorders                                                  Fainting/Dizzy Spells Additional comments or disorders not listed._______________________________________ WOMEN: ARE YOU PREGNANT OR COULD YOU POSSIBLY BE PREGNANT?___yes_____no I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Patient/Guardian Signature ___________________________________date_________________