Endo Medical History Form

MEDICAL / DENTAL HISTORY

Patient Name

Birthdate

Emergency Contact Name

Spouse / Parent / Other

Phone

Please select YES or NO to the following medical questions below

Do you require antibiotics before dental treatment?

Y N

PRE-MED DOSAGE

Your current physical health is:

Excellent Good Fair Poor

38.

Y N

Have you ever had a root canal before? If so, how would you rate your last root canal experience?

39.

Y N

Is there anything we can do to make you more comfortable during your visit in our office today?

STAFF ONLY:

DATE:

BP:

PULSE:

STAFF INIT:

DATE:

BP:

PULSE:

STAFF INIT:

DATE:

BP:

PULSE:

STAFF INIT:

MEDICAL / DENTAL HISTORY

PATIENT NAME

Please list all physicians and their specialty:

Family Physician:

Specialty:

Phone:

Address:

Date of Last Visit:

Physician:

Specialty:

Phone:

Address:

Date of Last Visit:

Physician:

Specialty:

Phone:

Address:

Date of Last Visit:

Physician:

Specialty:

Phone:

Address:

Date of Last Visit:

Please list any current medications you are taking and reason. Include prescriptions, supplements, and over the counter.

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during my diagnosis and treatment with my informed consent.

Signature

Date