• MEDICAL HISTORY

  • Birth Date:
     - -
  • 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 medication that you may be taking. 

  • Do you have a primary care provider?
  • Have you had any recent hospitalizations or major surgeries?
  • Do you have history of neck or head injuries?
  • Are you currently taking prescription medications and/or OTC supplements?
  • Do you have a history of oral or IV Bisphosphonates drugs (i.e. Fosamax, Boniva, Actonel, Reclast, Aredia)?
  • Do you use tobacco or have a history of use?
  • Women: Are you
  • Are you allergic to any of the following?
  • Rows
  • Have you ever had any medical condition not listed above?

  • 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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  • Should be Empty: