Waukesha Family Dentistry - Medical History Form

Patient Name(*)

Please provide the patient or guardian's full name.

Date of Birth(*)

Please provide patient's date of birth.

Physician's Name

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Physician's Address

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Are you currently under a physician's care?

Yes

Invalid Input

Physician's Phone

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Since When?

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Why?

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When was your last complete physical?

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General Medical History

Please choose the appropriate option for each question.

Please provide any additional information if asked - or write "don't know" in the line after the question.

Are you taking any medications or substances?

YesNo Invalid Input

Please list any medications

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Do you routinely take vitamins, supplements, or other natural health products?

YesNo Invalid Input

Please list any other health related substances you are taking.

Invalid Input

Have you ever had a serious illness or major surgery?

YesNo Invalid Input

Please explain

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Are you pregnant (or suspect you may be?)

YesNo Invalid Input

Do you use any birth control medications?

YesNo Invalid Input

Date of last menstrual period

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Please list

Invalid Input

Allergies & Sensitivities History

Are you allergic to any medications or substances?

YesNo Invalid Input

Do you have any other allergies or hives?

YesNo Invalid Input

Please list any allergies.

Invalid Input

Do you have any problems with penicillin, antibiotics, anesthetics, or any other medications?

YesNo Invalid Input

Are you sensitive to any metals or latex?

YesNo Invalid Input

History of Medical Conditions

Have you ever taken Fosamax, Zometa, Aredia, or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis?

YesNo Invalid Input

Do you have any stomach problems?

YesNo Invalid Input

Please describe the nature of your stomach problems

Invalid Input

Do you have any kidney problems?

YesNo Invalid Input

Please describe the nature of your kidney problems

Invalid Input

Do you have any liver problems?

YesNo Invalid Input

Please describe the nature of your liver problems

Invalid Input

Do you smoke, chew, use snuff, or any other forms of tobacco?

YesNo Invalid Input

What forms of tobacco and how often?

Invalid Input

Do you habitually use controlled substances?

YesNo Invalid Input

Please describe

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Have you had psychiatric treatment?

YesNo Invalid Input

Have you taken fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?

YesNo Invalid Input

Other Medical History

Do you have any disease, condition, or problem not listed?

YesNo Invalid Input

Please explain

Invalid Input

Is there anything else we should know about your health that we have not covered in this form?

YesNo Invalid Input

Please explain

Invalid Input

Would you like to speak to the Doctor privately about any problem or concern?

YesNo Invalid Input

I certify that the above information is complete and accurate. Invalid Input

Electronic Signature(*)

Sign Above

Please provide an electronic signauture