Patient name Birth date: ID #
Check if you have or have had problems with any of the following:
Medications routinely used in dental treatment may interact with both prescription and a number of illegal street drugs. Check the medications you are presently taking, medications you have taken in the past, or medications you have had an adverse reaction to:
List the other medications you are currently taking and what condition you are taking them for. Include vitamins, supplements, herbs and over the counter medications.
Pharmacy name: Phone:
Check your current use of:
Tobacco Yes No Packs per day
Alcohol, Beer, Wine Yes No Drinks per day
Street Drugs Yes No Times per day
Caffeine Yes No Cups per day
High Stress Yes No Reason
Women: Are you pregnant: Yes No Nursing? Yes No
Have you had any serious illnesses or surgeries: Yes No If yes, describe:
Do you have any other health needs you should bring to our attention?
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
Patient/Guardian signature _______________________________________
Please fill out this form and print it before your first appointment. Download PDF here.