Medical History

Patient Name:

Birth Date:

Date Created:

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.

Are you currently under the care of a physician?

Yes No

If yes, kindly provide additional information.

Are you taking any prescription medications?

Yes No

If yes, kindly provide additional information.

Preferred pharmacy?

Yes No

If yes, kindly provide additional information.

Are you taking any over the counter medications, vitamins, or other dietary or herbal supplements?

Yes No

If yes, kindly provide additional information.

Have you ever been hospitalized or had a major operation?

Yes No

If yes, kindly provide additional information.

Have you taken or plan on taking bisphosphonates? (Including: Fosamax, Boniva, Actonel, Reclast)

Yes No

If yes, kindly provide additional information.

Do you smoke? If yes, how much? How long have you smoked?

Yes No

If yes, kindly provide additional information.

Do you use smokeless tobacco?

Yes No

Women: Are you...

Pregnant?

Gestational Diabetes?

Trying to get pregnant?

Preclampsia?

Nursing?

Are you allergic to any of the following?

Aspirin

Metal

Penicillin

Latex

Codeine

Sulfa Drugs

Acrylic

Local Anesthetics

If yes, what was your reaction?

Other allergies?

Yes No

If yes, kindly provide additional information.

Do you have any of the following?

AIDS/HIV Positive

Yes No

Alzheimer's Disease

Yes No

Drug Addiction

Yes No

Easily Winded

Yes No

Rheumatism

Yes No

Artificial Heart Valve

Yes No

Hypoglycemia

Yes No

Irregular Heartbeat

Yes No

Spina Bifida

Yes No

Frequent Headaches

Yes No

Low Blood Pressure

Yes No

Seasonal Allergies

Yes No

Heart Attack/Failure

Yes No

Pain in Jaw Joints

Yes No

Parathyroid Disease

Yes No

Autism

Yes No

Hyperthyroidism

Yes No

Cortisone Medicine

Yes No

Diabetes

Yes No

Hepatitis B or C

Yes No

Angina

Yes No

Arthritis/Gout

Yes No

Excessive Bleeding

Yes No

Sickle Cell Disease

Yes No

Sinus Trouble

Yes No

Blood Transfusion

Yes No

Liver Disease

Yes No

Cancer

Yes No

Mitral Valve Prolapse

Yes No

Osteoporosis

Yes No

Tumors or Growths

Yes No

Heart Trouble/Disease

Yes No

ADHD

Yes No

Hypothyroidism

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Renal Dialysis

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Shingles

Yes No

Asthma

Yes No

Blood Disease

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Lung Disease

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Congenital Heart Disorder

Yes No

Psychiatric Care

Yes No

Controlled Substances

Yes No

Radiation Treatments

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Artificial Joint

Yes No

Fainting Spells/Dizziness

Yes No

Kidney Problems

Yes No

Breathing Problems

Yes No

Bruise Easily

Yes No

Chemotherapy

Yes No

Chest Pains

Yes No

Cold Sores/Fever Blisters

Yes No

Heart Pacemaker

Yes No

Adult Jaundice

Yes No

Head/Neck Injury

Yes No

Have you ever had any serious illness not listed?

Yes No

If yes, kindly provide additional information.

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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.

Signature of Patient, Parent or Guardian:

Date:

Your information will be encrypted.