Medical History Form

Patient's Name

Preferred Name

Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO" response.

Have been hospitalized (illness or injury)

Presently being treated for any other illnesses

Taking medication for weight control (ie fen-phen)

Taking dietary supplements

Subject to frequent headaches

A smoker or smoked previously

Currently or previously taken Fosamax, Boniva, Actonel or any other medication containing bisphosphonates

FEMALES ONLY

Taking contraceptives

Pregnant or planning pregnancy

Using Hormone Replacement Therapy

Nursing

If any conditions or alerts selected above need further clarification, please describe below

Have you had an orthopedic total joint replacement (hip,knee,elbow,finger), if so, please include date and description below. Also include any complications from procedure

Do you take antibiotic premedication for your dental visits?

Yes No

If yes, please explain:

Have you been out of the country in the last 6 months?

Yes No

What is your estimate of your general health?

Excellent

Good

Fair

Poor

Name of your physician and your most recent physical exam

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment

List all medications, drugs, pills or herbal remedies, including regular dosages of aspirin.

List all allergies: medications, latex, food, etc

Name and phone number of your preferred pharmacy

By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.

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

Date

Your information will be encrypted.