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Medical history

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PATIENT MEDICAL HISTORY

Name
Sex*
If female please answer the following:
Please answer the following:
Are you taking Birth Control Pills?*
Do you smoke or use tobacco?*
Are you pregnant?*
For Office Use Only
For Office Use Only
For Office Use Only
Are you nursing?*
Conditions
Conditions
Abnormal Bleeding*
Glaucoma*
Alcohol Abuse*
HIV+ AIDS*
Allergies*
Heart Attack*
Anemia*
Heart Surgery*
Angina Pectoris*
Hemophilia*
Arthritis*
Hepatitis A*
Artificial Heart Valve*
Hepatitis B*
Asthma*
Hepatitis C*
Bisphosphonate Medications*
High Blood Pressure*
Blood Transfusion*
Kidney Problems*
COVID 19*
Liver Disease*
Cancer- Chemotherapy*
Low Blood Pressure*
Colitis*
Mitral Valve Prolapse*
Congenital Heart Defect*
Pace Maker*
Diabetes*
Pneumocystitis*
Difficulty Breathing*
Psychiatric Problems*
Drug Abuse*
Radiation Therapy*
Emphysema*
Rheumatic Fever*
Epilepsy*
Seizures*
Fainting Spells*
Shingles*
Fever Blisters*
Sickle Cell Disease*
Frequent Headaches*
Sinus Problems*
Stroke*
Thyroid Problems*
Tuberculosis*
Ulcers*
Venereal Disease*
Yellow Jaundice*

Allergies

Aspirin*
Codeine*
Dental Anesthetics*
Erythromycin*
Jewelry*
Latex*
Metals*
Penicillin*
Tetracycline*
Medications
1
2
3
 
Is there any disease, condition, or problem that you think this office should know about that is not covered above? If yes, please describe below...*
(If Under 18, Parent or Guardian Signature Required)
Dated*
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We are committed to providing our patients with the highest of standards in a comfortable and relaxed environment.

Contact Details

  • Spring Hill Dental Care 21900 S Webster St. Spring Hill, KS 66083
  • info@springhilldentalcare.com
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