www.westwooddentistryma.com - Medical History

Medical History
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If so, please tell us about your treatment*
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If so, please tell us about the hospitalization*
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If so, please tell us about the head/neck injury*
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Please list all medications and dosage*
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Please tell us about your diet*
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Please tell us how often and what type of tobacco consumption*
Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.
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Please tell us about the antibiotics*
YesNo
If so, please tell us about your PhenFen/Redux usage*
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If so, please tell us about your bisphosphonate usage*
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If so, please tell us which controlled substances and amount/frequency*
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Please tell how much alcohol and how recently*
PregnantTrying to get pregnantCurrently nursingTaking oral contraceptivesNone of the above
AspirinIodineMetalPenicillinValiumAcrylicLatexNovocaineSulfa DrugsXylocaineErythromycinLocal AnestheticsNitrous OxideTetracyclineNone of the AboveOther
If other, please list*
AnemiaCortisone MedicationFrequent HeadachesHigh Blood PressureLiver DiseaseRheumatismStrokeArthritis or GoutCongenital Heart ProblemsEmphysemaHeart Valve or PacemakerLung DiseaseUlcers or GI ProblemsConvulsionsFrequent DiarrheaHepatitis (B or C)LeukemiaRenal DiseaseStomach/Intestinal DiseaseYellow JaundiceCancerEating DisorderHeart TroubleJaw Joint PainTumor or GrowthChemotherapyExcessive BleedingHay FeverHives or RashParathyroid DiseaseShinglesThyroid DiseaseBlood DiseaseDiabetesFrequent UrinationHerpesRheumatic FeverAsthmaEasily WindedGenital HerpesLow Blood PressureMitral Valve ProlapseScarlet FeverSwelling of LimbsArtificial JointCurrently PregnantEpilepsy or SeizuresHepatitis (A)Psychiatric CareX-ray/ChemotherapyCold Sores/Fever BlistersFrequent CoughHemophiliaKidney ProblemsRecent Weight LossSpina BifidaVenereal DiseaseBruise EasilyDrug/Alcohol AddictionHeart MurmurHypoglycemiaTuberculosisChest PainsExcessive ThirstHeart Attack/Heart FailureIrregular HeartbeatRadiation TreatmentsSickle Cell DiseaseTonsillitisBlood TransfusionDizziness or FaintingGlaucomaHIV-AIDS-ARCSinus ProblemsNo to All
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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.
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Medical History

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