Health History Form

Health Update

Patient Name:

DOB

Are you under a physician’s care now?

Yes No

Have you ever been hospitalized or had a major operation?

Yes No

If yes, please describe

Have you ever had a serious head or neck injury?

Yes No

Are you taking any medications, pills, or drugs?

Yes No

Add another medication

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 bisphonates?

Yes No

Are you on a special diet?

Yes No

If yes, please list details:

Add another special diet detail

Do you use tobacco?

Yes No

Do you use controlled substances?

Yes No

Women: Please mark if it applies:

Pregnant/trying to get pregnant

Nursing?

Taking oral contraceptives?

Are you allergic to? Please mark if it applies:

Aspirin

Acrylic

Latex

Penicilin

Aspirin

Sulfa Drugs

Codeine

Metal

Local Anesthetics

Other:

Other Concerns:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date:

Your information will be encrypted.