Medical History Form

Patient Information

Last Name

First Name

Middle Initial

E-mail

Birth date

Medical History

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.

Physician's Name

Date of Last Visit

Are you under a physician's care for special treatment? (Cancer, Diabetes, Heart Conditions, etc.)

Yes No

If Yes, please describe

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

If Yes, please describe

Are you taking any medications, pills, or drugs?

Yes No

If Yes, please describe

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

Yes No

If Yes, please describe

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

Yes No

If Yes, please describe

Are you on a special diet?

Yes No

Do you use tabacco?

Yes No

Women: Are you...

Are you pregnant?

Yes No

Nursing?

Yes No

Taking oral contraceptives?

Yes No

Are you allergic to any of the following?

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Do you use controlled substances?

Yes No

If Yes, please describe

Other?

If Yes, please describe

Have you ever had any serious illness not listed?

Yes No

If Yes, please describe

Comments

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