MEDICAL HISTORY

Patient 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. Thank you for answering the following questions.

Are you under a physician's care now? *

Yes No

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

Yes No

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

Yes No

Are you taking any medications, pills, or drugs? *

Yes No

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

Yes No

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

Yes No

Are you on a special diet? *

Yes No

Do you use tobacco? *

Yes No

Do you use controlled substances? *

Yes No

Women: Are you...

Pregnant/trying to get pregnant? Taking oral contraceptives? Nursing?

Are you allergic to any of the following?

Latex Penicillin Codeine Local Anesthetics Acrylic Metal Sulfa Drugs Other

AIDS/HIV Positive: *

Yes No

Alzheimer's Disease: *

Yes No

Anaphylaxis: *

Yes No

Anemia: *

Yes No

Angina: *

Yes No

Arthritis/Gout: *

Yes No

Artificial Heart Valve: *

Yes No

Artificial Joint: *

Yes No

Asthma: *

Yes No

Blood Disease: *

Yes No

Blood Transfusion: *

Yes No

Breathing Problem: *

Yes No

Bruise Easily: *

Yes No

Breathing Problem: *

Yes No

Cancer: *

Yes No

Chemotherapy: *

Yes No

Chest Pains: *

Yes No

Cold Sores/Fever Blisters: *

Yes No

Congenital Heart Disorder: *

Yes No

Convulsions: *

Yes No

Cortisone Medicine: *

Yes No

Diabetes: *

Yes No

Drug Addiction: *

Yes No

Easily Winded: *

Yes No

Emphysema: *

Yes No

Epilepsy or Seizures: *

Yes No

Excessive Bleeding: *

Yes No

Excessive Thirst: *

Yes No

Fainting Spells/Dizziness: *

Yes No

Frequent Cough: *

Yes No

Frequent Diarrhea: *

Yes No

Frequent Headaches: *

Yes No

Genital Herpes: *

Yes No

Glaucoma: *

Yes No

Hay Fever: *

Yes No

Heart Attack/Failure: *

Yes No

Heart Murmur: *

Yes No

Heart Pacemaker: *

Yes No

Heart Trouble/Disease: *

Yes No

Hemophilia: *

Yes No

Hepatitis A: *

Yes No

Hepatitis B or C: *

Yes No

High Blood Pressure: *

Yes No

High Cholesterol: *

Yes No

Hives or Rash: *

Yes No

Hypoglycemia: *

Yes No

Irregular Heartbeat: *

Yes No

Kidney Problems: *

Yes No

Leukemia: *

Yes No

Liver Disease: *

Yes No

Low Blood Pressure: *

Yes No

Lung Disease: *

Yes No

Mitral Valve Prolapse: *

Yes No

Osteoporosis: *

Yes No

Pain in Jaw Joints: *

Yes No

Parathyroid Disease: *

Yes No

Psychiatric Care: *

Yes No

Radiation Treatments: *

Yes No

Recent Weight Loss: *

Yes No

Renal Dialysis: *

Yes No

Rheumatic Fever: *

Yes No

Rheumatism: *

Yes No

Scarlet Fever: *

Yes No

Shingles: *

Yes No

Sickle Cell Disease: *

Yes No

Sinus Trouble: *

Yes No

Spina Bifida: *

Yes No

Stomach/Intestinal Disease: *

Yes No

Stroke: *

Yes No

*

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 n medical status.

Signature of Patient, Parent or Guardian: *