Medical-History-Form-big-4.1

Patient Name*

Birth Date*

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.

Are you under a physician's care now?*

NoYes (please explain)

Have you ever been hospitalized or had a major operation?*

NoYes (please explain)

Have you ever had a serious head or neck injury?*

NoYes (please explain)

Have you ever taken oral or injectable bisphosphonates?*

NoYes

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

NoYes

Are you on a special diet?*

NoYes

Do you use tobacco?*

NoYes

Women: Are you

Pregnant/ Trying to get pregnant?*

NoYes

Taking oral contraceptives?*

NoYes

Nursing?*

NoYes

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*

NoYes

Cortisone Medicine*

NoYes

Hemophilia*

NoYes

Renal Dialysis*

NoYes

Alzheimer's Disease*

NoYes

Diabetes*

NoYes

Hepatitis A*

NoYes

Rheumatic Fever*

NoYes

Anaphylaxis*

NoYes

Drug Addiction*

NoYes

Hepatitis B or C*

NoYes

Rheumatism*

NoYes

Anemia*

NoYes

Easily Winded*

NoYes

Herpes*

NoYes

Scarlet Fever*

NoYes

Angina*

NoYes

Emphysema*

NoYes

High Blood Pressure*

NoYes

Shingles*

NoYes

Arthritis/Gout*

NoYes

Epilepsy or Seizures*

NoYes

Hives or Rash*

NoYes

Sickle Cell Disease*

NoYes

Artificial Heart Valve*

NoYes

Excessive Bleeding*

NoYes

Hypoglycemia*

NoYes

Sinus Trouble*

NoYes

Artificial Joint*

NoYes

Excessive Thirst*

NoYes

Irregular Heartbeat*

NoYes

Spina Bifida*

NoYes

Asthma*

NoYes

Fainting Spells/ Dizziness*

NoYes

Kidney Problems*

NoYes

Stomach/ Intestinal Disease*

NoYes

Blood Disease*

NoYes

Frequent Cough*

NoYes

Leukemia*

NoYes

Stroke*

NoYes

Blood Transfusion*

NoYes

Frequent Diarrhea*

NoYes

Liver Disease*

NoYes

Swelling of Limbs*

NoYes

Breathing Problem*

NoYes

Frequent Headaches*

NoYes

Low Blood Pressure*

NoYes

Thyroid Disease*

NoYes

Bruise Easily*

NoYes

Genital Herpes*

NoYes

Lung Disease*

NoYes

Tonsillitis*

NoYes

Cancer*

NoYes

Glaucoma*

NoYes

Mitral Valve Prolapse*

NoYes

Tuberculosis*

NoYes

Chemotherapy*

NoYes

Hay Fever*

NoYes

Pain in Jaw Joints*

NoYes

Tumors of Growths*

NoYes

Chest Pains*

NoYes

Heart Attack/ Failure*

NoYes

Parathyroid Disease*

NoYes

Ulcers*

NoYes

Cold Sores/ Fever Blisters*

NoYes

Heart Murmur*

NoYes

Psychiatric Care*

NoYes

Venereal Disease*

NoYes

Congenital Heart Disorder*

NoYes

Heart Pace Maker*

NoYes

Radiation Treatments*

NoYes

Yellow Jaundice*

NoYes

Convulsions*

NoYes

Heart Trouble/ Disease*

NoYes

Recent Weight Loss*

NoYes

Have you ever had any serious illness not listed above?*

NoYes (please explain)

Please list ALL medications/drugs (prescription, over-the-counter, and recreational) that you are currently taking. Please include dosage and frequency. *

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.

Signature of Patient, Parent or Guardian*

Date*

Date

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