Current 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.
Do you have a primary care physician? If yes, please provide name and phone number.
Have you ever been hospitalized or had a major operation? If yes, what year did incident occur? Please explain
Have you ever had a serious head or neck injury?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you taking a blood thinner?
Do you use tobacco?
Do you use controlled substances?
Are you taking any medications, pills, or drugs?
Women: Are you...
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
Ulcers in mouth
Acid Reflux/ Gerd
High Blood Pressure
Low Blood Pressure
Pain in Jaw Joints
Stomach/ Intestinal Disease
Sickle Cell Disease
Mitral Valve Prolapse
Artificial Heart Valve
Congenital Heart Disease
Epilepsy or Seizures
Has a physcian recommended antibiotcs prior to dental treatment?
Have you had an orthopedic total joint replacement? (Hip, knee, elbow, finger)
Have you ever had any serious illness not listed above?
If you answered yes to any of the above, please explain:
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
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