Form

Medical History Form

Patient First Name

Patient Last Name

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? Routine or Specific Treatment?

If Yes

Have you ever been hospitalized or had a major operation?

If Yes

Have you ever had a serious head or neck injury?

If Yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

If Yes

Have you ever been told that you needed to pre-medicate with antibiotics before dental treatment?

If Yes

Have you had any type (either total or partial) of joint replacement surgery?

If Yes

Have you had a heart valve replacement or heart surgery?

If Yes

Have you had an organ/bone marrow/stem cell transplant?

If Yes

Do you use tobacco?

If Yes

Are you taking any medications, pills, or drugs?

If Yes

WOMEN: Are you...

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?

Additional Questions on Back

Do you have, or have you been diagnosed with, any of the following?

Heart (Cardiac) Health

Pacemaker/Implanted Defibrilator

Artificial (Prosthetic) Heart Valve

Previous Infective Endocarditis

Congenital Heart Disorder/Disease

Cardiac Transplant

Angina/Chest Pain

Heart Attack/Failure

Heart Murmur/Rythm Disorder

Stroke

Heart Trouble/Disease

High Cholesterol

Breathing (Respiratory) Health

Asthma

COPD

Emphysema

Sinus Trouble

Tuberculosis

Easily Winded

Breathing Problem

Lung Disease

Cancer

Tumors or Growths

Chemotherapy

Radiation

Blood (Circulatory) Health

Anemia

Blood Disorder/Disease

Blood Transfusion

High Blood Pressure

Low Blood Pressure

Bruise Easily

Excessive Bleeding

Syncope/Fainting Spells

Renal Dialysis

Swelling of Limbs

Brain (Neurological)/Mental Health

Anxiety/Depression

Epilepsy or Seizures

Alzheimer's

Psychiatric Care

Autoimmune Disease

HIV/AIDS

Lupus

Other Autoimmune Disease

Digestive Health

Acid Reflux/GERD

Stomach/Intestinal Disease

Stomach Ulcers

Other

Arthritis/Gout

Chronic Pain

Diabetes Type I or II

Drug Addiction/Abuse

Eating Disorder

Frequent Headaches/Migraines

Kidney Problems

Liver Disease

Cold Sores/Fever Blisters

Glaucoma

Thyroid Disease

Heptitis A

Hepatitis B or C

Osteoporosis

Shingles

Pain in Jaw Joints

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.

Patient, Parent or Guardian