[Imported Form] Medical History Form

York Family Dental Medical History
Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answerring the following questions.
Full Name

First NameLast Name
E-mail
Are you under a physician's care now?
If yes, please explain:
Ever been hospitalized/had a major operation?
If yes, please explain:
Have you ever had a serious head or neck injury?
If yes, please explain:
Are you taking any medication, pills or drugs?
If yes, please explain:
Do youtake, or have you taken Phen-Fen or Redux?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Women are you:
Women are you:
Are you Allergic to any of the following?
Allergies
If yes, please explain:
Do you have, or have you had and of the following:
Conditions & Symptoms
Have you had any serious illness not listed above? If so, please explain
Image Verification
Comments
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 infor the dental office of any changes in medical status.

Signature of Patient, Parent or Guardian: _________________________________________________________ Date: _________________
Should be Empty:

York Family Dental Medical History