Form

MEDICAL HISTORY

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.

Date

First Name

Last Name

Birth Date

Are you under the care of a physician?

Please explain

Have you ever been hospitalized or had a major operation?

Please explain

Have you ever had a serious head or neck injury?

Please explain

Are you taking any medications, pills or drugs?

Medication

Medication

Medication

Medication

Medication

Medication

Medication

Medication

Medication

Medication

Do you take, or have you taken, Phen-Fen or Redux?

Please explain

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

Please explain

Are you on a special diet?

Please explain

Do you use tobacco?

Please explain

Do you use controlled substances?

Please explain

Has a physician or previous dentist recommended that you take antibiotics or pre-medication prior to your dental appointment?

Please explain

Women: Are you?

Are you allergic to any of the following?

Do you have any other known allergies?

Please explain

Do you have or have you had any of the following diseases or medical conditions?

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?

Please explain

Comments

I certify that I have read and I understand the questions asked. I certify I have answered these questions in completion and do not hold the practice, doctor(s), or team responsible for any errors or omission that I have made in completing these forms.

I consent to the diagnostic procedures and treatment by the dentist(s) of this office necessary for proper dental care.

Signature (Patient or Guardian)

Date