• MEDICAL HISTORY

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry that you will be receiving. Thank you for answering the following questions. 

  • General Health (please check):*
  • Format: (000) 000-0000.
  • Date of Last Physical*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you now under the care of a physician?*
  • Are you pregnant or do you think you may be pregnant?*
  • Are you nursing?*
  • Are you taking birth control pills?*
  • Do you smoke?*
  • Are you taking medications now?*
  • If yes, names of medications and problems for which they are taken:
    Rows
  • Do you use tobacco?*
  • Have you ever taken Fen-Phen or Redux?*
  • Have you required a blood transfusion?*
  • Are you wearing contact lenses?*
  • Do you or have you used controlled substances?*
  • Do you bruise easily*
  • Have you ever had (please check-mark appropriate boxes)?*
    Rows
  • *
    Rows
  • Are you allergic to or have you had reactions to?*
    Rows
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: