Medical History Form

Medical History

"*" indicates required fields

Current physical health is :*
Are you allergic to any of the following?

Do you have or have you experienced any of the following?

Abnormal Bleeding*
Drug Abuse*
Memory Loss*
Acid Reflux*
Emphysema*
Mitral Valve Prolapse*
Alcohol Abuse*
Epilepsy*
Occlusal Appliance*
Arthritis*
Glaucoma*
Pacemaker*
Artificial Joints*
Headaches*
Psychiatric Care*
Artificial Valves*
Heart Murmur*
Radiation Treatment*
Asthma*
Heart Surgery*
Rheumatic Fever*
Blood Transfusion*
Hepatitis*
Sinus Problems*
Cancer*
HIV+/AIDS*
Snoring/Sleep Apnea*
Chemotherapy*
High Blood Pressure*
Stroke*
Congenital Heart Defect*
Hearing Impaired*
Thyroid Problems*
Depression*
Kidney Problems*
Tuberculosis (TB)*
Diabetes*
Liver Disease*
Ulcers*
Anxiety*
High Cholesterol*
Vertigo*
Autism*

Women :

Are you happy with the appearance of your smile?*
Consent*
MM slash DD slash YYYY