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 medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Have you ever had a serious head or neck injury?

YesNO
Are you taking any medication, pills, or druds (please include over the counter medications and any vitamins)

YesNo
Please list Medications:
Do you use controlled substances?

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

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

YesNo
Pregnant/Trying to get pregnant?

Yes
Nursing?

Yes
Taking oral medication?

Yes
Are you allergic to any of the following?

AspirinMetalPenicillianLatexCodeineSulfa DrugsAcrylicLocal Anesthetics
Do you have, or have you had, any of the following?

Alzheimer's DiseaseAIDS/HIV PositiveAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointsAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsions
Do you have, or have you had, any of the following?

Cortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/Disease
Do you have, or have you had, any of the following?

HemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteoporosisPain in Jaw JointsParathyroid DiseasePsychiatric Care
Do you have, or have you had, any of the following?

Radiation TreatmentsRecent Weight LossRenal DialysisRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpinal BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow JaundiceRheumatism Fever
Have you ever had any serious illness not listed above?
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.

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