ProSites, Inc.
MEDICAL HISTORY NAME: ______________________________________________________ DATE OF BIRTH: _____________Please circle the correct answer & clearly print requested information: Are you now under the care of a physician or have you been in the last 5 years? Yes NoIf yes, explain: ______________________________________________________________ Do you take any medicines regularly?Yes NoIf yes, list: ____________________________________________________________________________________________________________________________________________________________Do you have any drug allergies or sensitivities?Yes NoIf yes, list:______________________________________________________________________What was your reaction?__________________________________________________________Have you ever had any breathing difficulty or shortness of breath such as asthma, emphysema, tuberculosis, pneumonia, chronic cough, or lung disorder?YesNoIf yes, what & when: _____________________________________________________________Do you smoke?YesNoIf yes, what & how much:_________________________________________________________Are you subject to:faintingdizzinessconvulsionsepilepsyIf yes, explain:___________________________________________________________________Do you have any know heart disease or murmurs?Yes NoIf yes, explain: __________________________________________________________________Have you ever been asked to take antibiotics prior to dental work for any reason other than an infection?YesNoDo you have any artificial joints or heart valve replacements?YesNoIf yes, please list type and date of placement: _________________________________________Are you taking any blood thinners or aspirin?YesNoAre you or have you ever been subject to profuse bleeding following dental extractions, surgery or minor cuts?YesNoAt this time do you have a cold, cough, sinus trouble or hayfever?YesNoHave you ever had any of the following:Scarlet fever ______Rheumatic fever_____High Blood Pressure_____ Diabetes (type 1 or 2)_______Hepatitis______Anemia_________Liver Disease________Kidney Disease_______HIV/AIDS______ Stroke _______Is there anything else about your present or past medical history that you feel we should know?______________________________________________________________________________Weight_______________ Height ________________Are you pregnant?YesNoAre you taking birth control pills?YesNoDATE:_____________PATIENT OR GUARDIAN SIGNATURE:___________________________________ ................
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