MEDICAL HISTORY
 
Patient Name 
Birth Date  
 
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
  
Are you under a physician's care now?
If yes, please explain:
 
Have you ever been hospitalized or had a major operation?
If yes, please explain:
Have you ever had a serious head or neck injury?
If yes, please explain:
Are you taking any medications, pills, or drugs?
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?
If yes, please explain:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
If yes, please explain:
Are you on a special diet?
If yes, please explain:
Do you use tobacco?
 If yes, which?:
Do you use controlled substances?
 If yes, please explain:
 
Women: Are you
 
Pregnant/ Trying? Taking Oral Contra­ceptives? Nursing?
 
Are you allergic to any of the following?
If yes, please explain: 
Do you have, or have you had, any of the following?
AIDS/ HIV Positive
Cortisone Medicine
Hemophilia
Radiation Treat­ments
Alzhei­mer's Disease
Diabetes
Hepatitis A
Recent Weight Loss
Anaphy­laxis
Drug Addiction
Hepatitis B or C
Renal Dialysis
Anemia
Easily Winded
Herpes
Rheumatic Fever
Angina
Emphy­sema
High Blood Pressure
Rheu­matism
Arthritis Gout
Epilepsy or Seizures
High Choleste­rol
Scarlet Fever
Artificial Heart Valve
Excessive Bleeding
Hives or Rash
Shingles
Artificial Joint
Excessive Thirst
Hypo­glycemia
Sickle Cell Disease
Asthma
Fainting Spells-Dizziness
Irregular Heartbeat
Sinus Trouble
Blood Disease
Frequent Cough
Kidney Problems
Spina Bifida
Blood Trans­fusion
Frequent Diarrhea
Leukemia
Stomach/ Intestinal Disease
Breathing Problem
Frequent Headaches
Liver Disease
Stroke
Bruise Easily
Genital Herpes
Low Blood Pressure
Swelling of Limbs
Cancer
Glaucoma
Lung Disease
Thyroid Disease
Chemo­therapy
Hay Fever
Mitral Valve Prolapse
Tonsillitis
Chest Pains
Heart Attack-Failure
Osteop­orosis
Tuber­culosis
Cold Sores/ Fever Blisters
Heart Murmur
Pain in Jaw Joints
Tumors or Growths
Congenital Heart Disorder
Heart Pacemaker
Parathy­roid Disease
Ulcers
Convul­sions
Heart Trouble-Disease
Psychiatric Care
Venereal Disease
     
Yellow Jaundice

Have you ever had any serious illness not listed above?
 
Comments: 
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature (Patient or Guardian): 
DATE: