Health History Form Name* First Last Dental and Medical HistoryAbnormal BleedingYesNoAidsYesNoAlcoholismYesNoAnemiaYesNoArthritisYesNoAsthmaYesNoBleeding/Swollen GumsYesNoChemo TherapyYesNoChronic CoughYesNoCirculatory ProblemsYesNoClicking Jaw JointsYesNoConvulsionsYesNoDiabetesYesNoDrug AddictionYesNoEpilepsyYesNoFaintingYesNoFrequent HeadachesYesNoGastric BypassYesNoHeart TroubleYesNoHeart ValveYesNoHepatitisYesNoHigh Blood PressureYesNoHIV VirusAidsYesNoJoint ReplacementYesNoKidney DiseaseYesNoLap BandYesNoLeukemiaYesNoLiver DiseaseYesNoLow Blood PressureYesNoMalignancies-CancerYesNoMental IllnessYesNoMitral Valve ProlapseYesNoNervous ProblemsYesNoOperationsYesNoPace MakerYesNoRadiation TherapyYesNoRheumatic FeverYesNoRheumatismYesNoSinus ProblemsYesNoStrokeYesNoThyroid DiseaseYesNoTubucerlosisYesNoUlcersYesNoVenereal DiseaseYesNoDo 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?AllergiesAspirinYesNoPenicillinYesNoCodeineYesNoLocal AnestheticYesNoLatexYesNoSulfaYesNoOther AllergiesMedicationsList any medications you are currently taking - including any blood thinners (i.e. Aspirin, Vitamin E., Coumadin)Pharmacy NamePharmacy PhoneI 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* Date Format: MM slash DD slash YYYY