Medical History Form

Name*
First Last
Preferred Name
Email*
How do you prefer to be contacted?*
- E-mail
- Cell Phone
- Home Phone
- Work Phone
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Work Phone
Primary Dental Insurance
Insurance Name
Insured's DOB
Date Format: MM slash DD slash YYYY
ID #
Group #
Insured's Employers Name
Your current physical health is:*
- Good
- Fair
- Poor
Are you currently under the care of a physician?*
- Yes
- No
Please explain:
Do you smoke or use tobacco in any form?*
- Yes
- No
Have you had any metal rods, pins or implants?*
- Yes
- No
Are you taking any prescription/over the counter drugs?*
- Yes
- No
Please list each one:*
For Women:
Are you taking birth control pills?
- Yes
- No
Are you pregnant?
- Yes
- No
Week #:
Are you nursing?
- Yes
- No
Have you ever had any of the following diseases or medical problems?
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
Glaucoma*
- 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 pos/AIDS*
- Yes
- No
Hospitalized for any reason*
- Yes
- No
Kidney Problems*
- Yes
- No
Liver Disease*
- Yes
- No
Low Blood Pressure*
- Yes
- No
Mitral Valve Prolapse*
- Yes
- No
Pacemaker*
- Yes
- No
Psychiatric Problems*
- Yes
- No
Radiation Treatment*
- Yes
- No
Rheumatic/Scarlet Fever*
- Yes
- No
Seizures*
- Yes
- No
Sickle Cell Disease/Traits*
- Yes
- No
Sinus Problems*
- Yes
- No
Stroke*
- Yes
- No
Thyroid Problems*
- Yes
- No
Tuberculosis (TB)*
- Yes
- No
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following:
Aspirin*
- Yes
- No
Codeine*
- Yes
- No
Dental Anesthetics*
- Yes
- No
Erythromycin*
- Yes
- No
Latex*
- Yes
- No
Penicillin*
- Yes
- No
Tetracycline*
- Yes
- No
Other - Please list any other drugs/materials that you are alergic to:
Signature
Date
Date Format: MM slash DD slash YYYY
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We are always welcoming new patients and we would love to have you as part of our dental family. We love hearing from our patients and anyone who may be interested in becoming one. Learn more about our Kalamazoo dentist!

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Kalamazoo Smiles

5925 Venture Park Dr.
Kalamazoo, MI 49009

(269) 353-3700

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Medical History Form

For Women:

Have you ever had any of the following diseases or medical problems?

Are you allergic to any of the following: