Minneapolis Dental 150 South 5th Street, ste 1475 Minneapolis, MN 55402
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems you may have or medication
Are you under Physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use Tobacco?
Women: are you...
Pregnant/ Trying to get Pregnant?
Taking oral contraceptives?
Are you Allergic to any of the following?
Do you use controlled substances?
Do you have, or have you had, any of the following?
Hepatits B or C
High Blood Pressure
Epilepsy or Seizures
Artificial Heart Value
Hives or Rash
Low Blood Pressure
Mitral Valve Prolapse
Cold Sores/Fever Blisters
Pain In Jaw Joints
Congenital Heart Disorder
Recent weight loss
Sickle Cell Disease
Swelling of Limbs
Tumors or Growths
Have you ever had any serious illness not listed:
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.