• Medical History Form

  • Birth Date
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  • Date Created
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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,

  • Are you under a physician's care now?
  • Have you ever 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?
  • Do you take, or have you taken, Phen-Fen or Redux?
  • Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
  • Are you on a special diet?
  • Do you use tobacco?
  • Do you use controlled substances?
  • Women: Are you...
  • Are you allergic to any of the following?
  • Rows
  • Have you ever had any serious illness 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: