Health History Form Name* First Last Dental and Medical HistoryAbnormal Bleeding Yes No Aids Yes No Alcoholism Yes No Anemia Yes No Arthritis Yes No Asthma Yes No Bleeding/Swollen Gums Yes No Chemo Therapy Yes No Chronic Cough Yes No Circulatory Problems Yes No Clicking Jaw Joints Yes No Convulsions Yes No Diabetes Yes No Drug Addiction Yes No Epilepsy Yes No Fainting Yes No Frequent Headaches Yes No Gastric Bypass Yes No Heart Trouble Yes No Heart Valve Yes No Hepatitis Yes No High Blood Pressure Yes No HIV VirusAids Yes No Joint Replacement Yes No Kidney Disease Yes No Lap Band Yes No Leukemia Yes No Liver Disease Yes No Low Blood Pressure Yes No Malignancies-Cancer Yes No Mental Illness Yes No Mitral Valve Prolapse Yes No Nervous Problems Yes No Operations Yes No Pace Maker Yes No Radiation Therapy Yes No Rheumatic Fever Yes No Rheumatism Yes No Sinus Problems Yes No Stroke Yes No Thyroid Disease Yes No Tubucerlosis Yes No Ulcers Yes No Venereal Disease Yes No Do You Smoke? If yes, how much? Women OnlyAre you taking hormone replacement therapy? Are you taking birth control pills? Are you pregnant? Have you gone through menopause? AllergiesAspirin Yes No Penicillin Yes No Codeine Yes No Local Anesthetic Yes No Latex Yes No Sulfa Yes No Other Allergies MedicationsList any medications you are currently taking - including any blood thinners (i.e. Aspirin, Vitamin E., Coumadin) Pharmacy Name Pharmacy PhoneEmail* I understand that signing below constitutes a legal signature confirming that I acknowledge and agree to the above. The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form.Signature* Date* MM slash DD slash YYYY