Medical History Form
Date of Last Dental Cleaning
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 role with the dentistry you receive. Thank you for answering the following questions:
Are you under a physician's care now? If yes, Name or Group Name?
Have you ever had a serious head or neck injury? If yes, please explain.
Are you taking any medications, pills, or drugs? If yes, please explain.
Have you ever taken Fosamax, Boniva, or Actonel? If yes, please explain.
Do you use controlled substances? If yes, please explain.
Do you use tobacco?
Have you seen an orthodontist?
Have you been treated by an orthodontist?
Are you currently experiencing pain related to TMJ or other dental issues? If yes, please explain.
(Women) Are you pregnant/trying to get pregnant?
Are you allergic to any of the following?
If yes, please explain.
Do you have, or have you had, any of the following?
Artificial Heart Valve
Cold Sores/Fever Blisters
Congenital Heart Disease
Epilepsy or Seizures
Hepatitis B or C
High Blood Pressure
Hives or Rash
Low Blood Pressure
Mitral Valve Prolapse
Pain in Jaw Joints
Recent Weight Loss
Sickle Cell Disease
Swelling of Limbs
Tumors or Growths
Have you ever had any serious illness not listed above? If so, please explain.
Signature For Health History
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
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