Health History
Physician
Physicians Name
Date of Last Physical Exam
Address
Phone
Medical Questionnaire - Do you have or Have you had any of the following? (Click to check)
Any Heart Problems
High Blood Pressure
Low Blood Pressure
Circulatory Problems
Nervous Problems
Radiation Treatments
Excessive Bleeding
Anesthetic Allergies
Drug Allergies
Other Allergies
Anemia
Arthritis
Asthma
Diabetes
Hepatitis
Herpes
Malignancies (Cancer)
Measles
Mumps
Psychiatric Care
Scarlet Fever
Sinus Problems
Stroke
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
HIV/AIDS
Other
Are you Pregnant? Date Due
Birth Control Pill Prescription
Dental History
Previous Dentist
Address
Phone
Date of Last Appointment
Date of Last Cleaning
What is the purpose of this appointment?
I understand that the information that I provide on this form is essential to determine my dental needs and the provision of dental treatment. I understand that if any change occurs in my health I an to report it to the dental office as soon as possible. I have read and understand each question and have answered all of them truthfully and to the best of my ability. (Pressing submit button will constitute a signature and will submit your information to Glick Dental Associates).
Please note that if you receive an error message when submitting this form it can be alternatively printed and faxed to 440 349-0558.