HEALTH HISTORY

Medical History
Todays Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Date
Although dental personnel primarily treat your mouth, your mouth is 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 under a physician's care now?

YesNo
If yes
Have you ever been hospitalized or had a major operation in the last 5 years?

YesNo
If yes
Have you ever had a serious head or neck injury?

YesNo
If yes
Are you taking any medications, pills, or drugs?

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

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

YesNo
If yes
Are you on a special diet?

YesNo
Do you use tobacco?

YesNo
Do you use controlled substances?

YesNo
If yes
Women: Are you...

Pregnant/trying to get pregnantNursingTaking oral contraceptives
Are you allergic to any of the following?

AsprinMetalPenicillinLatexCodeineSulfa DrugsAcrylicLocal AnestheticsOther
Other allergy not listed:
Do you have, or have you had, any of the following? Please check all that apply.

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseaseHemophilaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatic FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
Have you ever had any serious illness not listed above?

YesNo
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.
Signature of Patient, Parent or Guardian:
Should be Empty:

Medical History