www.westwooddentistryma.com - Medical History - 7

  • Medical History

  • Format: (000) 000-0000.
  • Are you currently being treated by a physician for a specific condition?*
  • Have you recently 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?*
  • Are you on a special diet?*
  • Do you use tobacco?*

  • Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.

  • Have you ever been advised that you require antibiotics prior to a dental appointment?*
  • Do you take, or have you taken, PhenFen or Redux?*
  • Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates?*
  • Have you recently used controlled substances?*
  • Have you recently consumed alcohol? (Please answer if filling this form out on the day of your appointment)*
  • Women (Please check all that apply)*
  • Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic) *
  • Do you have, or have you ever had any of the following medical conditions? (Please select all that apply)*

  • 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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