Health History Form
Red fields are required.

First Name:
Last Name:
Birthdate: (mm/dd/yyyy)
Have you had implants such as
heart valves or joint replacement?
 Yes No
Do you have TMJ (jaw joint) problems?
 Yes No
Have any blood relatives had
reactions to anesthetic?
 Yes No
Have you recently taken a long-term
dose of oral cortisone?
 Yes No
Are you pregnant?
 Yes No
Are you wearing contact lenses?
 Yes No
Do you smoke or use tobacco?
 Yes No
Do you use recreational drugs?
 Yes No


Do you have or have you had
any of the following conditions?

Epilepsy
 Yes No
Heart Murmur
 Yes No
Mitral Valve Prolapse
 Yes No
Heart or Chest Palpations
 Yes No
Heart Surgery
 Yes No
Angina or Chest Pain
 Yes No
High Blood Pressure
 Yes No
Stroke
 Yes No
Severe Headache and/or Dizziness
 Yes No
Shortness of Breath
 Yes No
Persistent Cough
 Yes No
Tuberculosis (TB)
 Yes No
Asthma
 Yes No
Hepatitis
 Yes No
Stomach Ulcer
 Yes No
Glaucoma
 Yes No
Diabetes
 Yes No
Prolonged Bleeding Tendency
 Yes No
Do you wish to talk to
the Doctor privately?
 Yes No

Please list the allergies
to any medications:

Please list the medications
you are taking:

Please describe any other medical conditions not listed:

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