Dental Health History

Patient's Full Name*	Date of Birth*
Are you currently being treated by a physician regularly for a serious health problem? Yes,No
If yes, please explain and give physician’s contact information:
Please list all medications you are currently taking (prescribed or over the counter):
Do you have any known allergies to latex, medications, or milk protein (please list):
Have you ever been treated for: (check all that apply) Blood PressureHeart DiseaseStrokeArtificial JointRheumatic FeverHeart MurmurHeart ValvePacemakerHepatitisDiabetesDepressionTuberculosisImmune DiseaseAsthmaBleeding/ClottingDry Mouth
Has a physician told you to take antibiotics before a dental cleaning? Yes,No	If yes, why?
Do you use tobacco? YesNo	If yes, how much per day?
Do you consume alcohol? YesNo	If yes, how much per day/week?
Do you currently use recreational or street drugs? YesNo

I have read and completed the above answers to the best of my knowledge. I understand Krystal Teague Dental is not responsible for any missing information I did not provide above. I take full responsibility for any medications prescribed to me from Krystal Teague Dental.