Adult Medical History Form

Fill out your form online or download a copy.

Adult Medical History Form

"*" indicates required fields

Step 1 of 2

Patient Name*
MM slash DD slash YYYY
MM slash DD slash YYYY

Are you under a physician's care?*
Are you taking any medication, pills, or drugs?*
Are you allergic to any of the following?
Please check all that apply.
Do you have any other allergies?*

Women: Are you...

Do you have any of the following?

Alzheimer's*
Fainting Spells/Dizziness*
Liver Disease*
Anaphylaxis or Hives*
Frequent Headaches*
Low Blood Presssure*
Anemia*
Glaucoma*
Lung Disease*
Angina*
Heart Attack/Failure*
Osteoporosis*
Artificial Heart Valve*
Heart Pacemaker*
Pain in Jaw Joint(s)*
Arthritis*
Heart Trouble/Disease*
Parathyroid Disease*
Asthma*
Hepatitis A, B, or C*
Parkinson's Disease*
Bulimia or Anorexia*
Herpes*
Radiation to Head/Neck*
Chemotherapy*
High Anxiety or Depression*
Shingles*
Cold Sores/Fever Blisters*
High Blood Pressure*
Sinus Problems*
Diabetes*
Hypoglycemia*
Stomach Ulcers/GERD*
Drug Addiction*
Irregular Heartbeat*
Stroke*
Epilepsy or Seizures*
Kidney problems or Dialysis*
Thyroid Disease*
Excessive Bleeding*
Leukemia*
Tuberculosis*

Cancer*

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

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

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

Do you use tobacco?*

Clear Signature
Date*

Call The Office

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

Office Location

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