Advanced Family Dentistry Health History Form (Zionsville)

Health History Form
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you under a physician's care now?
If yes, please provide name and number
Have you ever been hospitalized or had a major operation?
Are you taking any medications, pills, or drugs?
If, yes please list current medications here.
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Formax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
WOMEN: Are you...
Are you allergic to any of the following? Check all that apply
Do you use controlled substances?
If yes, please list them here
Do you have or have you had, any of the following? Check all that apply.
Have you ever had a serious illness not listed?
If yes, what was the illness?
Comments:
To the best of my knowledge, the questions on this form have been accurately answered. I undertand 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.

See our privacy policy here.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty: