Medical History Template

Patient First Name:

Last 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 you may have or medication

Are you under Physician's care now?

Yes No

Have you ever been hospitalized or had a major operation?

Yes No

Have you ever had a serious head or neck injury?

Yes No

Are you taking any medications, pills or drugs?

Yes No

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

Yes No

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

Yes No

Are you on a special diet?

Yes No

Do you use Tobacco?

Yes No

Are you a Woman?

Yes No

Are you Allergic to any of the following?

Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics Other?

Do you use controlled substances?

Yes No

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

Have you ever had any serious illness not listed:

Yes No

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.

MEDICAL HISTORY FORM

Signature of Patient, Parent, or Guardian: