Medical Health History

Patient Name

Date of Birth

Primary Care Physician

Date of last physical

Physician Telephone

Do you consider yourself to be in good health?

Yes No

If no, explain.

Have you experienced any serious illnesses or operations?

Yes No

If yes, describe.

(WOMEN)

Are you pregnant

Nursing

Taking birth control pills

Please list medications you are currently taking in space provided below. Or we can attach your list.

Medications

Other Narcotics

Other Antibiotics

Other Allergies

Please check if you have or have had any of the following:

Describe Heart Problems

Other STD's

History of/or presently taking Bisphosphonates for Osteoporosis

Boniva

Fosamax

Actonel

Do you have any illness or medical condition not listed above that you think I should be aware of? Please explain.

My signature acknowledges this information to be an accurate account of my health history. I understand providing correct information is vital to my comprehensive dental care.

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.

Patient/Parent if minor/Guardian

Date

Medical Health History reviewed by Dr. Winkler

Date

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