Dr. Krochak: Medical History Form

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Medical History Form

Please fill out all these forms before your first visit:
☐ Medical History Form
☐ Patient Account Information
☐ Appointment Preference Form
☐ Corah's Dental Anxiety Scale
☐ Mount Sinai Dental Fear Inventory



First Name		Last Name

Address		City



State		Zip

Home Phone		Work Phone

Cell Phone		Email

Name of Spouse/Partner

If you are completing this form for another person, what is your relationship to that person?


Referred by


For the following questions, check YES or NO, whichever applies. Your answers are for our records only and are confidential.
Are you in good health?		YesNo
Has there been any change in your general health within the past year?		YesNo
My last physical examination was on
Are you now under the care of a physician?		YesNo
If Yes, what is the condition being treated?
The name and Address of my physician(s):
Have you had any serious illness, operation, or been hospitalized in the past 5 years?		YesNo
If so, what was the illness or problem?
Are you taking any medicine(s) including non-prescription medicine?

Do you have or have you had any of the following diseases or problems?

Damaged heart valves or artificial heart valves (including heart murmur or rheumatic heart disease):		YesNo
Cardiovascular disease (including heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke):		YesNo
a. Do you have chest pain upon exertion?		YesNo
b. Are you ever short of breath after mild exercise or when lying down?		YesNo
c. Do your ankle swell?		YesNo
d. Do you have inborn heart defects?		YesNo
e. Do you have a cardiac pacemaker?		YesNo

Allergy		YesNo
Sinus trouble		YesNo
Asthma or hay fever		YesNo
Fainting spells or seizures		YesNo
Persistent diarrhea or recent weight loss		YesNo
Diabetes		YesNo
Hepatitis, jaundice or liver disease		YesNo
Thyroid problems		YesNo
Respiration problems, emphysema, bronchitis, etc		YesNo
Aids or HIV infection		YesNo
Stomach ulcer or hyperacidity		YesNo
Kidney trouble		YesNo
Tuberculosis		YesNo
Persistent cough or cough that produces blood		YesNo
Persistent swollen glands in neck		YesNo
Low blood pressure		YesNo
Sexually transmitted disease		YesNo
Epilepsy or other neurological disease		YesNo
Problems with mental health		YesNo
Cancer		YesNo
Problem on immune system		YesNo

Have you had abnormal bleeding?		YesNo
Have you ever required a blood transfusion?		YesNo
Do you have any blood disorder?		YesNo
Have you ever had any treatment for a tumor or growth?		YesNo

Are you allergic or have you had a reaction to:
a. Local anesthetics		YesNo
b. Penicillin or other antibiotics		YesNo
c. Sulfa drugs		YesNo
d. Barbiturates, sedatives, or sleeping pills		YesNo
e. Aspirin		YesNo
f. Iodine		YesNo
g. Codeine or other narcotics		YesNo
h. Other		YesNo

Have you had any serious trouble associated with any previous dental treatment?		YesNo
If so, explain
Do you have any disease, condition or problem not listed above that you think we should know about?		YesNo
If so, explain
Are you wearing contact lenses?		YesNo
Are you wearing removable dental appliances?		YesNo
Do you smoke?		YesNo
If yes, how much?
Do you drink alcoholic beverages?		YesNo
If yes, how much and what type?

Women
Are you pregnant?		YesNo
Do you have any problems associated with your menstrual period?		YesNo
Are you nursing?		YesNo
Are you taking birth control pills?		YesNo

What is your chief dental complaint?

Any significant dental history we should know about?

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Click to certify.

If you have any problems or questions regarding these forms, please call our office at 212.838.2900. We will be glad to assist you.

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