Patient Medical and Dental History

Patient Name

Date

Dental History

Reason for today's visit

Date of last dental care

How often do you floss

How often do you brush?

Medical History

Although dental personnel primarily treat the area in and around 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 following questions.

Physician’s name

Date of last dental care

Are you under a physician’s care now?

Yes No

If yes, please explain.

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?

Yes No

Nursing?

Yes No

Taking birth control pills?

Yes No

Have you ever had any serious illness not listed above?

Yes No

If yes, please explain.

List medications you are currently taking:

Add new row

If other, please specify.

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

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

Signature of of Patient, Parent, Guardian or Personal Representative

Date

Please print name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

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