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201 Players Circle
Suite 100
Southlake, Texas 76092
817-481-4888




Patient Medical History

Patient First Name
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Patient Middle Name
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Patient Last Name
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Have you had a heart murmur or rheumatic fever?
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Have you had a heart attack?
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Do you have high or low blood pressure?
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Do you wear a pacemaker?
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Are you taking ANY medications?
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Have you had a reaction to an anesthetic?
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Do you have allergies or asthma?
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Are you allergic to any medication?
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Do you have a lung disease( tuberculosisform emphysema, etc.)?
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Do you have problems with your eyes (cataracts, glaucoma, etc.)?
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Do you have a kidney problem?
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Is there a history of diabetes in your family?
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Do you have a blood disorder (anemia, leukemia, hemophilia, etc.)?
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Have you had a stroke?
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Do you have AIDS or are you immunocompromized?
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Are you pregnant?
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# of months
Have you had seizures or a convulsive disorder?
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Have you had a tumor or cancer?
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Have you received chemo, cobalt, or radiation therapy?
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Are you currently under the care of a physician?
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Have you been hospitalized or had medical treatment in the last five years?
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Have you had x-rays in the past two years?
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Do you have stiff muscles or joints?
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Have you had an injury to your face or jaws?
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Are you a nervous or tense person?
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Have you had a problem with any dental procedure?
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Do you have any disease, problem or condition not listed?
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I certify that the above statements regarding my health are accurate and complete. I realize that such omissions may endanger my health or result in less than optimal treatment results.
Signature ___________________________ Date: _________

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