MEDICAL HISTORY

Medical History
So that we may provide you with the best possible care, it is important that you tell all dental personnel involved in your treatment about the general state of your health. Please complete this medical history form. This information is, of course, confidential.
Name

Patient First NamePatient Last Name
Date of Birth

MonthDayYear
Date
Phone number
Format: (000) 000-0000.
Today's Date

MonthDayYear
Date
If you are completing this form for another person, what is your relationship to that person?
Your Name
Relationship
MEDICAL HISTORY
Physician's name
Address
YesNo
if yes, for what reason?
YesNo
YesNo
YesNo
ALLERGIES / SENSITIVITIES
PencillinCodeineLocal AnestheticMetalsLATEXAspirinOther AntibioticsNONEOther Medications or Substances
Describe reaction
BISPHOSPHONATES
YesNo
YesNo
Date treatment began

MonthDayYear
Date
YesNo
How long ago did you quit?
CigarettesCigarsPipeChew
How much?
How Often?
YesNo
How Much?
How Often?
YesNo
How Much?
How Often?
YesNo
How Much?
How Often?
Do you have, or have you ever had any of the following: (YES OR NO)
YesNo
YesNo
Do you have or have you ever had any of the following (YES or NO)
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, please explain
Comments
I understand the information entered on this form is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any changes in my health or medication.
(Patient or Patient Guardian)
Date

MonthDayYear
Date
(Doctor or Provider of Care)
Date

MonthDayYear
Date
Should be Empty:

Medical History

MEDICAL HISTORY

ALLERGIES / SENSITIVITIES

BISPHOSPHONATES

Do you have or have you ever had any of the following (YES or NO)