Medical History

Welcome!

Name*

First NameLast Name

Medical History

Please indicate if any of the following apply:

Joint replacement?

YesNo

Which joint and when?

Cardiac treatment?

YesNo

Explain:

Take daily aspirin?

YesNo

Dose:

Do you take bloodthinners?

YesNo

Have you or are you currently taking any bisphosphonates (ie: Boniva, Fosamax, Reclast)

YesNo

Physician recommend or require antibiotics for dental procedures due to past surgeries?

YesNo

Date of surgery

Date

Are you taking any medication?

YesNo

Prescribed medications & associated medical conditions

Non-prescription (over the counter) medications, vitamins, natural or herbal supplements

Allergic to or adverse reaction to the following: (explain reaction)

Local anesthesia

YesNo

If yes, please explain:

Demerol/Narcotic

YesNo

Reaction:

Epinephrine

YesNo

Reaction:

Aspirin

YesNo

Reaction:

Ibuprofen

YesNo

Reaction:

Barbiturates

YesNo

Reaction:

Penicillin

YesNo

Reaction:

Other antiobiotic

YesNo

Reaction:

Latex/Rubber dam

YesNo

Reaction:

Sulfa drugs

YesNo

Reaction:

Sedatives/Sleeping pills

YesNo

Reaction:

Codeine

YesNo

Reaction:

Reaction to metals

YesNo

Reaction:

Other allergic reactions

Please indicate if you have had any of the following diseases or conditions listed below

Date

Please indicate if you have had any of the following diseases or conditions listed below

Explain:

I give my consent to use local anesthetics, relaxants, nitrous oxide, or a combination for completing any necessary dental treatment

Anesthetic consent*

Date*

Date

Additional Information

Have there been any changes in your general health in the last 2 years such as serious illness, operation, or hospitalization?

YesNo

If so, what condition?

Are you now under the care of a physician?

YesNo

Are you presently being treated for an illness?

YesNo

If so, what condition(s)?

Name of condition/illness

Treating physician

Date of your last physical exam

Date

Physicians name

Medical History

Welcome!

Medical History

Allergic to or adverse reaction to the following: (explain reaction)

Additional Information

Do you have any of the following?

Alchohol/Drug/Tobacco Use

For Female Patients Only