Patient Registration Form
Records Release Form
Adult Medical History Form
Dental History for Adolescents and Adults Form
Child Medical and Dental History Form
HIPAA Notification of Privacy Policy

Adult Medical History Form

Fill out your form online or download a copy.

Adult Medical History Form

"*" indicates required fields

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Patient Name*

First Last

Patient Email

Patient Birth Date*

MM slash DD slash YYYY

Date Created*

MM slash DD slash YYYY

Are you under a physician's care?*

Yes

If yes, for what reason are you under a physician's care?*

Are you taking any medication, pills, or drugs?*

Yes

If so, please list and include reason for taking.*

Are you allergic to any of the following?

Please check all that apply.

Penicillin

Non-precious metals

Latex

Sulfa drugs

Tree Nuts

I am not allergic to any of the above.

Do you have any other allergies?*

Yes

If yes, please indicate other allergies.

Women: Are you...

Pregnant/trying to get pregnant

Nursing

Taking oral contraceptives

None of the above

Do you have any of the following?

Alzheimer's*

Yes

Fainting Spells/Dizziness*

Yes

Liver Disease*

Yes

Anaphylaxis or Hives*

Yes

Frequent Headaches*

Yes

Low Blood Presssure*

Yes

Anemia*

Yes

Glaucoma*

Yes

Lung Disease*

Yes

Angina*

Yes

Heart Attack/Failure*

Yes

Osteoporosis*

Yes

Artificial Heart Valve*

Yes

Heart Pacemaker*

Yes

Pain in Jaw Joint(s)*

Yes

Arthritis*

Yes

Heart Trouble/Disease*

Yes

Parathyroid Disease*

Yes

Asthma*

Yes

Hepatitis A, B, or C*

Yes

Parkinson's Disease*

Yes

Bulimia or Anorexia*

Yes

Herpes*

Yes

Radiation to Head/Neck*

Yes

Chemotherapy*

Yes

High Anxiety or Depression*

Yes

Shingles*

Yes

Cold Sores/Fever Blisters*

Yes

High Blood Pressure*

Yes

Sinus Problems*

Yes

Diabetes*

Yes

Hypoglycemia*

Yes

Stomach Ulcers/GERD*

Yes

Drug Addiction*

Yes

Irregular Heartbeat*

Yes

Stroke*

Yes

Epilepsy or Seizures*

Yes

Kidney problems or Dialysis*

Yes

Thyroid Disease*

Yes

Excessive Bleeding*

Yes

Leukemia*

Yes

Tuberculosis*

Yes

Cancer*

Yes

If yes, please indicate the type of cancer?*

Have you ever had any serious illness not listed above?*

Yes

If yes, please explain any serious illness?*

Does your physician require you to have antibiotics prior to dental treatment?*

Yes

If yes, please list condition and physician.*

Have you ever take Fosamax, Boniva, Actonel or any other medication containing bisphosphonates?*

Yes

If yes, please indicate.*

Do you use tobacco?*

Yes

If yes, list type and frequency of use.*

Please list the name of your primary care physician and any specialists you currently see.*

Please give any other information you feel is important for the dentist to know.

Signature of Patient, Parent, or Guardian*

Date*

Month

Day

Year

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Dental History for Adults and Adolescents

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Call The Office

(912) 489-1386
Fax: (912) 764-8533

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Office Location

2 Lester Court
Statesboro, GA 30458
Located across from Statesboro High School.

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Email Us

office@brayandyoung.com