broadwaydentalcare.net - Medical History

Medical History
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you currently being treated by a physician for a specific condition?*

YesNo
If so, please tell us about your treatment?
Have you recently been hospitalized to had a major operation?*

YesNo
If so, please tell us about your hospitalization?
Have you ever had a serious head or neck injury?*

YesNo
If so, please tell us about the head or neck injury
Are you taking any medications, pills or drugs ?*

YesNo
Please list all medications and drugs
Are you on a special diet?*

YesNo
Please tell us about your diet
Do you use tobacco?*

YesNo
Please tell us how often and what type of tobacco consumption
Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threating emergency.
Have you ever been advised that you require antibiotics prior to a dental appointment?*

YesNo
Please tell us about the antibiotics
Do you take, or have you taken, PhenFen or Redux?*

YesNo
If so, please tell us about your PhenFex/Redux usage.
Have you ever take, Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*

YesNo
If so, please tell us about your bisphosphonate usage
Have you recently used controlled substances?*

YesNo
If so, please tell us about which controlled substances and amount/frequency
Have you recently consumed alcohol?*

YesNo
Please tell us how much alcohol and how much recently.
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check all allergic)*

AspirinAcrylicErythromycinIodineLatexLocal AnestheticsMetalNovocainNitrous OxidePenicillinSulfa DrugsTetracyclineValiumXylocaineNone of the aboveOther
Do you have, or have you ever had any of the following medical conditions (Please select all that apply)*

AnemiaHay FeverRecent Weight LossArthritis or GoutFrequent UrinationTuberculosisFrequent DiarrheaMitral Valve ProlapseTonsilitisEating DisorderPsychiatric CareChemotherapyHemophiliaRheumatismBlood DiseaseHeart MurmurUlcers or GI ProblemsGenital HerpesRadiation TreatmentsYellow JaundiceEpilepsy or SeizuresSinus ProblemsCold Sores/Fever BlistersHigh Blood PressureShinglesBruise EasilyHeart Valve or PacemakerAsthmaHeart Attack/Heart FailureRenal DiseaseArtificial JointGlaucomaTumor or GrowthCortisone MedicationHives or RashSpina BifidaCongenital Heart ProblemsHerpsChest PainsHepatitis(B or C)Scarlet FeverBlood TransfusionHeart TroubleX-ray/ChemotherapyExcessive BleedingKidney ProblemsStrokeDiabetesHypoglycemiaConvulsionsLow Blood PressureSickle Cell DiseaseCancerHepatitis (A)Frequent CoughLiver DiseaseThyroid DiseaseDrug/Alcohol AddictionLung DiseaseEasily WindedIrregular HeartbeatStomach/Intestinal DiseaseCurrently PregnantHIV-AIDS-ARCFrequent HeadachesParathyroid DiseaseVenereal DiseaseEmphysemaRheumatic FeverExcessive ThirstLeukemiaSwelling of LimbsDizziness or FaintingJaw Joint PainNo to all
Do you have any condition or problem, not listed, which we should know about? Please explain
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. *

YesNo
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