• W. Springfield ● Rolla ● Osage Beach ● Mountain Grove ● E. Springfield 1-877-Dentist ● www.access.dental

    W. Springfield ● Rolla ● Osage Beach ● Mountain Grove ● E. Springfield 1-877-Dentist ● www.access.dental

  • Birth Date*
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  • 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 madications 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 taken oral or injectable bisphosphonates?*
  • Do you take, or have you taken, Phen-Fen or Redux?*
  • Are you on a special diet?*
  • Do you use tobacco?*

  • Women: Are you

  • Pregnant/ Trying to get pregnant?*
  • Taking oral contraceptives?*
  • Nursing?*
  • Are you allergic to any of the following?*

  • Do you have, or have you had, any of the following? Please check each circle Yes or No

  • AIDS/HIV Positive*
  • Cortisone Medicine*
  • Hemophilia*
  • Renal Dialysis*
  • Alzheimer's Disease*
  • Diabetes*
  • Hepatitis A*
  • Rheumatic Fever*
  • Anaphylaxis*
  • Drug Addiction*
  • Hepatitis B or C*
  • Rheumatism*
  • Anemia*
  • Easily Winded*
  • Herpes*
  • Scarlet Fever*
  • Angina*
  • Emphysema*
  • High Blood Pressure*
  • Shingles*
  • Arthritis/Gout*
  • Epilepsy or Seizures*
  • Hives or Rash*
  • Sickle Cell Disease*
  • Artificial Heart Valve*
  • Excessive Bleeding*
  • Hypoglycemia*
  • Sinus Trouble*
  • Artificial Joint*
  • Excessive Thirst*
  • Irregular Heartbeat*
  • Spina Bifida*
  • Asthma*
  • Fainting Spells/ Dizziness*
  • Kidney Problems*
  • Stomach/ Intestinal Disease*
  • Blood Disease*
  • Frequent Cough*
  • Leukemia*
  • Stroke*
  • Blood Transfusion*
  • Frequent Diarrhea*
  • Liver Disease*
  • Swelling of Limbs*
  • Breathing Problem*
  • Frequent Headaches*
  • Low Blood Pressure*
  • Thyroid Disease*
  • Bruise Easily*
  • Genital Herpes*
  • Lung Disease*
  • Tonsillitis*
  • Cancer*
  • Glaucoma*
  • Mitral Valve Prolapse*
  • Tuberculosis*
  • Chemotherapy*
  • Hay Fever*
  • Pain in Jaw Joints*
  • Tumors of Growths*
  • Chest Pains*
  • Heart Attack/ Failure*
  • Parathyroid Disease*
  • Ulcers*
  • Cold Sores/ Fever Blisters*
  • Heart Murmur*
  • Psychiatric Care*
  • Venereal Disease*
  • Congenital Heart Disorder*
  • Heart Pace Maker*
  • Radiation Treatments*
  • Yellow Jaundice*
  • Convulsions*
  • Heart Trouble/ Disease*
  • Recent Weight Loss*

  • 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.  

  • Date*
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