Step 1 of 3 33% Medical-Dental History FormName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last DOB: MM DD YYYY Marital Status: Single Married Divorced Sex: Female Male Social Security Number:Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:Cell Phone:E-Mail Address: Date of Last Physical Exam: MM DD YYYY Have you ever been a patient in a hospital or had any serious illness?NoYesExplain: Check any of the following that you have taken or are currently taking: Anticoagulants Blood Thinners Cortisone Drugs Tranquilizers Sedatives Steroids Are you allergic to or do you suffer ill effects from any of the following? Penicillin Dental Anesthesia Aspirin Household Bleach Codeine Other(s) List Other(s):Do you smoke? No Yes Do you drink alcohol? No Yes Are you pregnant? No Yes How many months?Are you breastfeeding? No Yes Are you taking medication? No Yes If yes, please list them below: Check any of the following that you have had or suspected: AIDS/HIV Anemia Arthritis Asthma Bladder Trouble Blood Disease Blood Transfusion Cancer Chest Pain Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Tendency Glaucoma Hay Fever Heart Disease Heart Murmur Heart Trouble Hepatitis High Blood Pressure Jaundice Kidney Disease Liver Disease Low Blood Pressure Lung Disease Mental Disorders Pacemaker Prosthetic Joint Replacement Radiation Treatment Rheumatic Fever Sinus Trouble Shortness of Breath Stroke Thyroid Disease Tuberculosis Tumor Venereal Disease Other(s) Check the box. By checking this box and typing my name below, I am electronically signing my application.Patient/Legal Guardian Name (signature): First Last PhoneThis field is for validation purposes and should be left unchanged.