Medical History Form

    MEDICAL HISTORY

    Patient

    Are you currently under the care of a physician?

    Have you ever had any serious illnesses or operations?
    YesNo

    Have you ever taken Bisphosphonates (IV or Oral)? If yes, please list type and dates taken

    Have you ever had head or neck radiation therapy?
    YesNo

    Are you taking any blood thinners? If yes, which one(s)

    List all medications you are taking:

    Are you allergic to:
    PenicillinClindamycinSulfa DrugsCodeineLatex
    Women Only
    Are you pregnant?
    YesNo
    Nursing?
    YesNo
    Taking Birth Control
    YesNo

    Please check if you have/had:

    Allergies, hay fever, sinusitis
    YesNo
    Emphysema
    YesNo
    Pacemaker
    YesNo
    Anemia
    YesNo
    Epilepsy
    YesNo
    Respiratory disease
    YesNo
    Arthritis, Rheumatism
    YesNo
    Fainting
    YesNo
    Rheumatic fever
    YesNo
    Artificial heart valve(s)
    YesNo
    Headaches
    YesNo
    Shortness of breath
    YesNo
    Artificial joint (s)
    YesNo
    Heart Murmur
    YesNo
    Sickle Cell Anemia
    YesNo
    Asthma
    YesNo
    Heart Problems
    YesNo
    Sinus trouble
    YesNo
    Bleeding abnormally with surgery
    YesNo
    Hepatitis type
    YesNo
    Stroke
    YesNo
    Blood disease, clotting disorders
    YesNo
    Herpes
    YesNo
    Slow healing wounds
    YesNo
    Cancer
    YesNo
    High blood pressure
    YesNo
    Swelling of ankles/feet
    YesNo
    Chemical dependency
    YesNo
    Immune deficiency
    YesNo
    Thyroid problems
    YesNo
    Chemotherapy
    YesNo
    Jaundice
    YesNo
    Tonsillitis
    YesNo
    Circulatory problems
    YesNo
    Kidney disease
    YesNo
    Tuberculosis
    YesNo
    Long term cortisone/steroid use
    YesNo
    Low blood pressure
    YesNo
    Tumor or growths
    YesNo
    Cough, persistent
    YesNo
    Mitral Valve prolapse
    YesNo
    Ulcers
    YesNo
    Diabetes
    YesNo
    Osteoporosis/osteopenia
    YesNo
    Venereal Disease
    YesNo

    DENTAL HISTORY:

    Have you had an allergic reaction to local or general anesthetics?
    YesNo
    Have you ever had trouble with/from prior dental treatment?
    YesNo



    Dentist in Sunrise and Weston, FL

    Westgate Dental

    Call Us Today

    954-389-9600

    Location

    Westgate Dental
    15810 W State Rd 84 #1227,
    Sunrise, FL 33326

    Office Hours

    Monday: 8:00 am – 5:00 pm
    Tuesday: 9:00 am – 5:00 pm
    Wednesday: 8:00 am – 5:00 pm
    Thursday: 9:00 am – 5:00 pm
    Friday: 8:00 am – 1:00 pm
    Saturday & Sunday: Closed

    Schedule An Appointment Today!