PATIENT HEALTH HISTORY INFORMATION 18.0 Date: Patient Name (Last, First, MI): Birth Date %PatientNameLast%, %PatientNameFirst% %PatientNameMiddle% (MM/DD/YYYY) ALLERGIES - Select all that apply: Aspirin Allergy Codeine Allergy Erythromycin Allergy Hay Fever Latex Allergy Penicillin Allergy Sulfa Allergy Other Allergy: MEDICATIONS - Please list any medications you are currently taking including vitamins and dietary supplements Please check this box if your physician or previous dentist recommended you take antibiotics prior to your dental treatment. Please check this box if you are taking additional medications not listed here. Bring a list to your appointment.