Patient Health History

First Name

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. 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

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

Women: Are you..

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin

Acrylic

Sulfa Drugs

Penicillin

Metal

Local Anesthetics

Codeine

Latex

Other

If other, Please specify

Do you use controlled substances?

Yes No

If Other, Please specify

Have you ever had any serious illness not listed above?

Yes No

Comments

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