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About
Founders
Instructors
FAQs
Reviews
Courses
Dental Assistant
CPR and BLS
Coronal Polish
Infection Control & DPA
Pit & Fissure Sealant
Dental Assistant Radiology
RDA Written Review
Jobs
Find a Job
Post a Job
Resources
Class Videos
Course Forms
Contact
Call Us: 714-882-5518
Updated Health
Medical History Form
Updated Health Medical History Form
Name
Your Physician’s Name
Date of Birth
Your Physician’s Address
Briefly describe your general health
Checkbox Field
Measles
Jaundice
Epilepsy
Venereal disease
Diabetes
Rheumatic fever
Tuberculosis
Chicken Pox
Heart Attack
Hepatitis
Mumps
Stroke
Ulcers
Asthma
Thyroid Disease
Anemia
Liver Disease
Emotional disease
Have you been examined by a physician in the last year?
Yes
No
Hasthere been any change in your health in the last year?
Yes
No
Have you ever had surgery? (An operation)
Yes
No
Please specify
Have you gained or lost much weight recently?
Yes
No
Have you ever been treated for ear or eye trouble, other than corrective glasses?
Yes
No
Do you bleed for a long time when you cut yourself?
Yes
No
Have you ever had hives or a skin rash?
Yes
No
Have you ever been told you have heart trouble?
Yes
No
Do you get out of breath easily?
Yes
No
Do you have spells of dizziness?
Yes
No
Do your ankles ever become badly swollen?
Yes
No
Do you have high blood pressure?
Yes
No
Have you ever been told that you have a heart murmur?
Yes
No
Do you have any blood disorder?
Yes
No
Do you have asthma, hay fever, sinusitis or frequent sore throat?
Yes
No
Have you ever had tuberculosis, emphysema or other lung disease?
Yes
No
Do you have stomach trouble, frequent diarrhea or constipation?
Yes
No
Have you ever been told you have kidney or bladder trouble?
Yes
No
Have you ever had syphilis or gonorrhea?
Yes
No
Do you ever have fits, convulsions or seizures?
Yes
No
Do you have arthritis or joint trouble?
Yes
No
Are your joints often painfully swollen?
Yes
No
Have you had a general or local anesthetic?
Yes
No
Have you often had toothaches?
Yes
No
Do your gums bleed when you brush your teeth?
Yes
No
Do your gums itch when you brush your teeth?
Yes
No
Does it hurt when you chew?
Yes
No
Do you have any problems with your jaws?
Yes
No
Do you clench or grind your teeth?
Yes
No
Have you ever had an injury to your face, neck or jaw?
Yes
No
Do you suffer from frequent or severe headaches, neck or back pain?
Yes
No
Have you ever received x-ray or radiation therapy to the head or neck?
Yes
No
Do you have ear pain or pain in front of the ears?
Yes
No
Does your jaw feel tired after a big meal?
Yes
No
Must you chew on one side exclusively?
Yes
No
Is your sleep disturbed by pain of the head and neck region?
Yes
No
Are your daily activities or routine disturbed by pain of the head and neck region?
Yes
No
Do you consider yourself a nervous person?
Yes
No
Do you fee unhappy or depressed?
Yes
No
Are you easily upset?
Yes
No
Are you sensitive or allergic to any medicine
Yes
No
Are you sensitive or allergic to any of the following?
Penicillin
Novocain
Aspirin
Iodine
Codeine
Sleeping pills
Other
Please specify
Do you smoke or use tobacco?
Yes
No
Do you drink alcohol daily?
Yes
No
WOMEN – Are you pregnant?
Yes
No
WOMEN – Are you in or have passed through menopause (change of life)?
Yes
No
When did you last have radiographs (Full Mouth X-rays – 18-20 images) taken?
List all Prescription and Non-Prescription drugs taken or used in the past 3 months:
Submit Form
