www.identalomaha.com - Medical History Form

Medical History
Name *

First Name Last Name
Email Address *
example@example.com
Phone Number *
Please enter a valid phone number.
Gender *
Are you currently being treated by a physician for a specific condition? *

Yes No
If so, please tell us about your treatment *
Have you recently been hospitalized or had a major operation? *

Yes No
If so, please tell us about the hospitalization *
Have you ever had a serious head or neck injury? *

Yes No
If so, please tell us about the head/neck injury *
Are you taking any medications, pills, or drugs? *

Yes No
Please list all medications and dosage (Click + add more) *
Are you on a special diet? *

Yes No
Please tell us about your diet *
Do you use tobacco? *

Yes No
Please tell us how often and what type of tobacco consumption *
Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.
Have you ever been advised that you require antibiotics prior to a dental appointment? *

Yes No
Please tell us about the antibiotics *
Do you take, or have you taken, PhenFen or Redux? *

Yes No
If so, please tell us about your PhenFen/Redux usage *
Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates? *

Yes No
If so, please tell us about your bisphosphonate usage *
Have you recently used controlled substances? *

Yes No
If so, please tell us which controlled substances and amount/frequency *
Have you recently consumed alcohol? *

Yes No
Please tell how much alcohol and how recently *
Please answer if filling this form out on the day of your appointment
Women (Please check all that apply)

Pregnant Trying to get pregnant Currently nursing Taking oral contraceptives None of the above
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic) *

Aspirin Acrylic Erythromycin Iodine Latex Local Anesthetics Metal Novocaine Nitrous Oxide Penicillin Sulfa Drugs Tetracycline Valium Xylocaine None of the Above Other
If other, please list *
Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *

Anemia Chemotherapy Cold Sores/Fever Blisters Cortisone Medication Excessive Bleeding Frequent Cough Frequent Headaches Hay Fever Hemophilia High Blood Pressure Hives or Rash Kidney Problems Liver Disease Parathyroid Disease Recent Weight Loss Rheumatism Shingles Spina Bifida Stroke Thyroid Disease Venereal Disease Arthritis or Gout Blood Disease Bruise Easily Congenital Heart Problems Diabetes Drug/Alcohol Addiction Emphysema Frequent Urination Heart Murmur Heart Valve or Pacemaker Herpes Hypoglycemia Lung Disease Rheumatic Fever Tuberculosis Ulcers or GI Problems Asthma Chest Pains Convulsions Easily Winded Excessive Thirst Frequent Diarrhea Genital Herpes Heart Attack/Heart Failure Hepatitis (B or C) Low Blood Pressure Irregular Heartbeat Leukemia Mitral Valve Prolapse Radiation Treatments Renal Disease Scarlet Fever Sickle Cell Disease Stomach/Intestinal Disease Swelling of Limbs Tonsillitis Yellow Jaundice Artificial Joint Blood Transfusion Cancer Currently Pregnant Dizziness or Fainting Eating Disorder Epilepsy or Seizures Glaucoma Heart Trouble Hepatitis (A) HIV-AIDS-ARC Jaw Joint Pain Psychiatric Care Sinus Problems Tumor or Growth X-ray/Chemotherapy No to All
Do you have any condition or problem, not listed, which we should know about? *

Yes No
Please explain *
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 *

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Name *

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Date *

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