Form

Brammeier Family Dental Medical History

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. The ADA recommends updating health history at least every year or whenever there has been a major change in health. This information is necessary to provide safe and individualzed care. Thank you for answering the following questions.

Are you under a physician's care now?

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

Are you taking any medications, pills, or drugs?

If Yes

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

If Yes

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

If Yes

Have you in the past or do you currently use tobacco?

Women: Are you...

Are you allergic to any of the following?

If Yes

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

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis Reaction

Anemia

Angina / Chest Pain

Arthritis

Arrythmia

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disorder

Blood Transfusion

Bruise Easily

Cancer

Chemotherapy

Chronic Cough

Chronic Headache

Congenital Heart Disorder

Diabetes

Drug/Alcohol Dependency

Emphysema

Epilepsy or Seizures

Fainting Spells/Dizziness

Glaucoma

Heart Attack

Heart Disease

Heart Murmur

Heart Pacemaker

Hemophilia

Hepatitis A

Hepatitis B or C

High Blood Pressure/Hypertension

Kidney Disease

Leukemia

Liver Disease

Low Blood Pressure/Hypotension

Mitral Valve Prolapse

Oral Herpes/Cold Sores

Osteoporosis

Psychiatric Care

Radiation Treatments

Renal Dialysis

Respiratory Disease

Rheumatic / Scarlet Fever

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach/Intestinal Disease

Stroke

Thyroid Disease

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Have you ever had any serious illness not listed above?

If Yes

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