Form

Medical History

First Name

Last Name

Date Of Birth

Name of Medical Doctor

Doctor's Office Phone

City/State

Emergency Contact

Phone

Relationship

List all the medications and dosages you are now taking:

List all medications and substances that have given you an allergic or adverse reaction:

Have you ever taken bone loss prevention drugs such as Actonel, Fosamax, Boniva or any other Bisphosphonates?

Choice

List Bisphosphonates Taken:

Do you have or have you previously had any of the following medical conditions? (Please check Yes or No for each condition)

Heart (Surgery, Disease, Attack)

Hay Fever/Sinus/Allergy/Hives

Neurological Disorders

Artificial Heart Valve

Tuberculosis

Epilepsy or Seizures

Pacemaker

Emphysema

AIDS/HIV Positive

High Blood Pressure

Asthma

Hepatitis

Type

Stroke

Chronic Cough

Sexually Transmitted Disease

Diabetes

Latex Sensitivity

Cold Sores/Fever Blisters

Thyroid Problems

Glaucoma

Blood Transfusions

Joint Replacement

Contact Lenses

Bruise Easily

Type of Joint Replacement and Date of Surgery

Bleeding Problems

Low Blood Pressure

Diet (Special/Restricted)

Fainting/Dizziness/Vertigo

Swollen Ankles

Nervous/Anxious

Cortisone Medicine

Ulcers

Psychiatric/Psychological Care

Kidney Problems/Disease

Rheumatic Fever

Rheumatism/Arthritis

Congenital Heart Disease

Mitral Valve Prolapse

Liver Disease/Jaundice

Heart Murmur

Hemophilia

Chest Pain

Sickle Cell Disease

Radiation Therapy

Chemotherapy

Tumors

Cancer

Condition Not Listed

Type of Tumor and Date

Type of Cancer and Date

Please list any other disease, condition or problem

Have you had any medical care or been hospitalized in the past 2 years?

Please describe:

Women: Pregnant

Nursing

Currently using Birth Control Prescriptions

Preferred Pharmacy

Pharmacy Phone

I give my consent for the doctor to retrive and send electronic prescription and medical history information

I have answered the above questions to the best of my knowledge. I will notify the doctor of any change in my health or medication. I understand that the information provided above is critical to a safe and efficient dental experience

Patient Signature/Parent or Guardian Signature if Minor

Date