Medical History

Medical History
Patient Name*

Patient's First NamePatient's Last Name
Date*

MonthDayYear
Date
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
Are you under a physician's care now?*

YesNo
If yes
Have you ever been hospitalized or had a major operation?*

YesNo
If yes
Have you ever had a serious head or neck injury?*

YesNo
If yes
Are you taking any medications, pills, or drugs?*

YesNo
If yes
Do you take, or have you taken, Phen-Fen or Redux?*

YesNo
If yes
Have you ever taken Fosamax, Bonlva, Actonel or any other medications containing bisphosphonates?*

YesNo
If yes
Are you on a special diet?*

YesNo
Have you been diagnosed with sleep apnea?*

YesNo
Do you use tobacco?*

YesNo
Have you been told you snore?*

YesNo
Women: Are you*

Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?NA
Are you allergic to any of the following?*

AspirinMetalPenicillinLatexCodeineSulfa DrugsAcrylicLocal AnestheticsNAOther
Do you use controlled substances?*

YesNo
If yes
Do you have, or have you had, any of the following?

AIDS/HIV PositiveAlzheimer's DiseaseAnemiaAnaphylaxisAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseaseHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
Have you ever had any serious illness not listed?*

YesNo
If yes
Comments
Emergency Name & Phone Number
Emergency Name
Emergency Phone
Please enter a valid phone number.
To the best of my knowledge, the questions on this form have been accuratety 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.
Signature of Patient, Parent or Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Emergency Name & Phone Number