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COMPREHENSIVE MEDICAL HISTORY
First and Last Name______________________________Birth Date ______/_______/______
(please print)
month
day
year
Allergies

No Known Allergies
Iodine
Plastic
Antibiotics
Latex
Sedatives
Aspirin
Local Anesthetics
Sleeping Pills
Barbiturates
Metals
Sulfa Drugs
Codeine
Penicillin
Tetracycline
Current Medications
Medicine
Dosage/Frequency
Reason
Medical History
Medical Condition
Never/Current/Past
Acid Reflux
Anemia
Arteriosclerosis
Arthritis
Asthma
Autoimmune Disorder
Bleeding Easily
Blood Pressure-High
Blood Pressure-Low
Bruising Easily
Cancer
Chemotherapy
Chronic Fatigue


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Notes
Medical Condition
Never/Current/Past
Hepatitis
Hypoglycemia


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
Immune System Disorder
Ischemic Heart Disease
Kidney Problems
Liver Disease
Meniere’s Disease
Mitral Valve Prolapse
Multiple Sclerosis
Muscular Dystrophy
Mood Disorder
Nasal Allergies
Neuralgia
Notes
Chronic Pain
COPD
CPAP/BiPAP
Depression
Diabetes
Difficulty Sleeping
Dizziness
Emphysema
Epilepsy
Fibromyalgia
Glaucoma
Gout
Heart Attack


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

Osteoarthritis
Osteoporosis
Parkinson’s Disease
Pregnancy
Psychiatric Care
Radiation Treatment
Rheumatic Fever
Rheumatoid Arthritis
Sinus Problems
Sleep Apnea
Snoring
Stroke
Heart Disorder
Heart Murmur
Heart Pacemaker
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



Thyroid disorder
Tuberculosis
Tumors
Urinary Disorders
Heart Valve Replacement
Hemophilia
Tendency for Ear
Infections
Prior Orthodontic
Treatment

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

Please list any additional Medical Conditions:



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

Confidential Medical History:
Recreational Drug Use

HIV/AIDS

I agree that the information provided above is to the best of my knowledge.
Name__________________________________________________ Date_________________
(Patient’s Signature)
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