Form

Medical History Information

First Name

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 may have , or medication that you may be taking, could have an important interrelationship with the dentistry you will recieve.

Are you under a primary physician's care?

If Yes

Have you ever been hopitalized or had major operation in the last 5 years?

If Yes

Have you ever had a serious head or neck injury?

If Yes

Are you taking any medications, pills, drugs, or herbal supplements?

If Yes

Do you take or have you ever taken Fosamax, Boniva, Actonel, medications which contain bisphosphonates?

If Yes

Are you on a special diet?

If Yes

Do you use tobacco?

If Yes

Do you use controlled substances?

If Yes

Have you had complications or allergic reactions to dental treatment?

If Yes

Women: Are you...

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin

Metal

Local Anesthetics

Penicillin

Latex

Acrylic

Codeine

Sulfa Drugs

Other?

If Yes

Do you have, or have you had, any of the following?

AIDS/HIV positive

Dementia

Anaphylaxis

Anemia

Angina

Arthritis

Artificial Joint

Asthma

Blood Disease

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Herpes/Cold sores/Fever Blisters

Congenital Heart Disease

Convulsions

Steroids

Diabetes

Drug Addiction

Emphysema

COPD

Epilepsy/Seizures

Fainting Spells/Dizziness

Frequent Headaches

Glaucoma

Hay Fever

Heart Attack/Failure

Heart Murmur

Heart Pacemaker

Hemophillia

Hepatitis

High Blood Pressure

Low Blood Pressure

High Cholesterol

Hives/ Rash

Irreugular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain in Jaw Joints

Parathyroid Disease

Psychiatric Care

Radiation Treatment

Renal Dialysis

Rheumatic Fever

Rheumatism

Shingles

Sickle Cell Disease

Sinus Trouble

Stomach/Intestinal Disease

Stroke

Swelling of limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growth

Ulcers

Venereal Disease

Yellow Jaundice

Depression

Gout

Have you ever had any serious illness not listed above?

If Yes

Comments:

FOR OFFICE STAFF USE ONLY:

ASA Classification:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerours to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical history.

Patient, Parent or Guardian