Medical History

MEDICAL HISTORY FORM

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?

Nursing?

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?

AID/HIV Positive

Cortisone Medicine

Hemophilia

Alzheimer's Disease

Diabetes

Hepatitis A

Anaphylaxis

Drug Addiction

Hepatits B or C

Anemia

Easily Winded

Herpes

Angina

Emphysema

High Blood Pressure

Arthritis/Gout

Epilepsy or Seizures

High Cholesterol

Artificial Heart Value

Excessive Bleeding

Hives or Rash

Artificial Joint

Excessive Thirst

Hypoglycemia

Asthma

Fainting Spells/Dizziness

Irregular Heartbeats

Blood Disease

Frequent Cough

Kidney Peoblems

Blood Transfusion

Frequent Diarrhea

Leukemia

Breathing Problems

Frequent Headaches

Liver Disease

Bruise Easily

Genital Herpes

Low Blood Pressure

Cancer

Glaucoma

Lung Disease

Chemotherapy

Hay Fever

Mitral Valve Prolapse

Chest Pains

Heart Attack/Failure

Osteoporosis

Cold Sores/Fever Blisters

Heart Murmur

Pain In Jaw Joints

Congenital Heart Disorder

Heart Pacemaker

Parathyroid Disease

Convulsions

Heart Trouble/Disease

Psychiatric Care

Radiation Treatments

Recent weight loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach/Intestinal Disease

Stroke

Swelling of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Yellow Jaundice

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.

Signature of Patient, Parent, or Guardian: