Minneapolis Dental 150 South 5th Street, ste 1475 Minneapolis, MN 55402

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Medical History

MEDICAL HISTORY FORM

"*" indicates required fields

Patient First Name*

Last Name*

Email*

Phone Number*

Birth Date*

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?

YES

NO

If Yes

Have you ever been hospitalized or had a major operation?

YES

NO

If Yes

Have you ever had a serious head or neck injury?

YES

NO

If Yes

Are you taking any medications, pills or drugs?

YES

NO

If Yes

Do you take, or have you taken, Phen-Fen or Redux?

YES

NO

If Yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

YES

NO

If Yes

Are you on a special diet?

YES

NO

Do you use Tobacco?

YES

NO

Women: are you...

Pregnant/ Trying to get Pregnant?

YES

NO

Nursing?

YES

NO

Taking oral contraceptives?

YES

NO

Are you Allergic to any of the following?

Aspirin

YES

NO

Penicillin

YES

NO

Codeine

YES

NO

Acrylic

YES

NO

Metal

YES

NO

Latex

YES

NO

Sulfa Drugs

YES

NO

Local Anesthetics

YES

NO

Other?

YES

NO

If Yes

Do you use controlled substances?

YES

NO

If Yes

Do you have, or have you had, any of the following?

AID/HIV Positive

YES

NO

Cortisone Medicine

YES

NO

Hemophilia

YES

NO

Alzheimer's Disease

YES

NO

Diabetes

YES

NO

Hepatitis A

YES

NO

Anaphylaxis

YES

NO

Drug Addiction

YES

NO

Hepatits B or C

YES

NO

Anemia

YES

NO

Easily Winded

YES

NO

Herpes

YES

NO

Angina

YES

NO

Emphysema

YES

NO

High Blood Pressure

YES

NO

Arthritis/Gout

YES

NO

Epilepsy or Seizures

YES

NO

High Cholesterol

YES

NO

Artificial Heart Value

YES

NO

Excessive Bleeding

YES

NO

Hives or Rash

YES

NO

Artificial Joint

YES

NO

Excessive Thirst

YES

NO

Hypoglycemia

YES

NO

Asthma

YES

NO

Fainting Spells/Dizziness

YES

NO

Irregular Heartbeats

YES

NO

Blood Disease

YES

NO

Frequent Cough

YES

NO

Kidney Problems

YES

NO

Blood Transfusion

YES

NO

Frequent Diarrhea

YES

NO

Leukemia

YES

NO

Breathing Problems

YES

NO

Frequent Headaches

YES

NO

Liver Disease

YES

NO

Bruise Easily

YES

NO

Genital Herpes

YES

NO

Low Blood Pressure

YES

NO

Cancer

YES

NO

Glaucoma

YES

NO

Lung Disease

YES

NO

Chemotherapy

YES

NO

Hay Fever

YES

NO

Mitral Valve Prolapse

YES

NO

Chest Pains

YES

NO

Heart Attack/Failure

YES

NO

Osteoporosis

YES

NO

Cold Sores/Fever Blisters

YES

NO

Heart Murmur

YES

NO

Pain In Jaw Joints

YES

NO

Congenital Heart Disorder

YES

NO

Heart Pacemaker

YES

NO

Parathyroid Disease

YES

NO

Convulsions

YES

NO

Heart Trouble/Disease

YES

NO

Psychiatric Care

YES

NO

Radiation Treatments

YES

NO

Recent weight loss

YES

NO

Renal Dialysis

YES

NO

Rheumatic Fever

YES

NO

Rheumatism

YES

NO

Scarlet Fever

YES

NO

Shingles

YES

NO

Sickle Cell Disease

YES

NO

Sinus Trouble

YES

NO

Spina Bifida

YES

NO

Stomach/Intestinal Disease

YES

NO

Stroke

YES

NO

Swelling of Limbs

YES

NO

Thyroid Disease

YES

NO

Tonsillitis

YES

NO

Tuberculosis

YES

NO

Tumors or Growths

YES

NO

Ulcers

YES

NO

Venereal Disease

YES

NO

Yellow Jaundice

YES

NO

Have you ever had any serious illness not listed:

YES

NO

If Yes

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.

Date*

Minneapolis Dental 150 S 5th St, ste 1475 Minneapolis, MN 55402