West Georgia Family Dentistry: west georgia family dentistry douglasville ga: On-line Health History

   general & cosmetic
     8590 Bowden St.
Douglasville, GA 30134
       770 949-1680

Medical History

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Patient's Name *

Date *

Physician's Name

Last Medical Exam

Do you have any Drug Allergies or ever had an adverse reaction to any medication ? *

no yes

If so, what?

Has a physician directed you to take antibiotics prior to having dental treatment? *

no yes

If yes, please take your pre-med antibiotic as prescribed by your physician prior to your appointment.

Please check if you have any of the following:

Heart Disease

Heart Murmur

Mitral Valve Prolapse

Rheumatic Fever

High Blood Pressure

Low Blood Pressure

Stroke

Heart Surgery

Congenital Heart Disease

Heart Pacemaker

Artificial Heart Valve

Latex Allergies

Arthritis

Hemophilia

Diabetes

Hypoglycemia

Glaucoma

Psychiatric Care

Oral or Other Cancer

Stomach Ulcers

Kidney Problems

Osteoporosis

Thyroid/Parathyroid Problems

Emphysema or Asthma

Tuberculosis

Persistent Cough

Sinus Trouble

History of Convulsions

Epilepsy

STDs

Herpes/Cold Sores

Immunodeficiency

AIDS or HIV

Other

Do you have a severe dental fear or phobia? *

no yes

Are you under the care of a physician at this time? *

no yes

If so, what conditions ?

Have you been a patient in a hospital during the past two years ? *

no yes

Have you been under a doctor's care during the past two years ? *

no yes

Have you ever responded adversely to medical or dental treatment ? *

no yes

Are you currently taking any medication? *

no yes

If so, what ?

For women:

Are you or do you suspect that you are pregnany ?

no yes

Are you nursing ?

no yes

Are you taking birth control pills ?

no yes

( * Required Field )