• Medical History Update

  • Date of birth
     - -
  • Format: (000) 000-0000.
  • Have you taken any medication or drugs during the past two years?
  • Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?
  • Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other bisphosphonates?
  • Are you aware of having an allergic (or adverse) reaction to any substance or medication?
  • Have you been a patient in the hospital during the past five years?

  • Indicate which of the following you have had, or have at present. Select "yes" or "no" to each item.

  • Rows
  • Rows
  • Have you lost or gained more than 10 pounds in the past year?
  • Do you have or have you had any disease, condition, or problem not listed?

  • Women

  • Are you pregnant or think you could be pregnant?
  • Nursing?
  • Do you currently use prescription birth control?

  • I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

  • Date
     - -
  • Date of Last Dental Visit
     - -
  • Date of Last Dental Cleaning
     - -
  • Date of Last Full Mouth X-rays
     - -
  • Format: (000) 000-0000.
  • Have you ever used or are currently using topical fluoride?
  • Do you have any dental problems now?
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Do you feel nervous about having dental treatment?
  • Have you ever had an upsetting dental experience?
  • Have you ever been told to take a pre-medication prior to dental treatment?
  • Is there anything else about having dental treatment that you would like us to know?
  • Should be Empty: