MEDICAL HISTORY 10

Please answer yes or no AND provide additional information for all yes answers

Are you currently under a physician's care now?

Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs?

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

Are you on a special diet?

Do you use tobacco?

Do you use controlled substances?

Are you taking oral contraceptives?

Are you pregnant or trying to get pregnant?

nursing?

Please list any allergies to the following:

Aspirin, Penicillin, Sulfa Drugs, Codeine,

Metals, Latex, Acrylic, Local Anesthetic, or any others?

Please list any of the following medical conditions, including any serious illness not listed that apply:

AIDS/HIV ALZHEIMERS ANAPHYLAXIS ANEMIA ARTHRITIS/GOUT ARTIFICIAL HEART VALVE ARTIFICIAL JOINT ASTHMA BLOOD DISEASE BLOOD TRANSFUSION BREATHING PROBLEMS BRUISE EASILY CANCER CHEMOTHERAPY CHESTPAINS COLD SORES/BLISTERS CONGENITAL HEART DISORDER CONVULSIONS

CORTISONE MEDICINE DIABETES DRUG ADDICTION EASILY WINDED EMPHYSEMA EPILEPSY OR SEIZURES EXCESSIVE BLEEDING EXCESSIVE THIRST FAINTING SPELLS/DIZZINESS FREQUENT COUGH FREQUENT DIARRHEA FREQUENT HEADACHES GENITAL HERPES GLAUCOMA HAY FEVER HEART ATTACK/FAILURE HEART MURMUR HEART PACEMAKER HEART TROUBLE/DISEASE

HEMOPHILIA HEPATITIS A HEPATITIS B OR HERPES HIGH BLOOD PRESSURE HIGH CHOLESTROL HIVES OR RASH HYPOGLYCEMIA IRREGULAR HEARTBEAT KIDNEY PROBLEMS LEUKEMIA LIVER DISEASE LOW BLOOD PRESSURE LUNG DISEASE MITRAL VALVE PROLAPSE OSTEOPROSIS PAIN IN JAW JOINTS PARATHYROID DISEASE PSYCHIATRIC CARE

RADIATION TREATMENTS RECENT WEIGHT LOSS RENAL DIALYSIS RHEUMATIC FEVER RHEUMATISM SCARLET FEVER SHINGLES SICKLE CELL DISEASE SINUS TROUBLE SPINA BIFIDA STOMACH/INTESTINAL DISEASE STROKE SWELLING OF LIMBS THYROID DISEASE TONSILLITIS TUBERCULOSIS TUMORS OR GROWTHS ULCERS VENERAL DISEASE YELLOW JAUNDICE

Medical conditions

To the best of my knowledge the questions on this form have been accurately answered. I understand providing incorrect information can be dangerous to my health It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient Parent or Guardian

Date