• Neligh Family Dental - Online Patient Medical History Form

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  • Do you, 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:

  • Pregnant/Trying To Get Pregnant?*
  • Taking Oral Contraceptives?*
  • Nursing*
  • Are you allergic to any of the following:*
  • AIDS/HIV Positive*
  • Cortisone Medicine*
  • Hemophilia*
  • Radiation Treatments*
  • Alzheimer's Disease*
  • Diabetes*
  • Hepatitis A*
  • Recent Weight Loss*
  • Anaphylaxis*
  • Drug Addiction*
  • Hepatitis B or C*
  • Renal Dialysis*
  • Anemia*
  • Easily Winded*
  • Herpes*
  • Rheumatic Fever*
  • Angina*
  • Emphysema*
  • High Blood Pressure*
  • Rheumatism*
  • Arthritis/Gout*
  • Epilepsy or Seizures*
  • High Cholesterol*
  • Scarlet Fever*
  • Artificial Heart Valve*
  • Excessive Bleeding*
  • Hives or Rash*
  • Shingles*
  • Artificial Joint*
  • Excessive Thirst*
  • Hypoglycemia*
  • Sickle Cell Disease*
  • Asthma*
  • Fainting Spells/Dizziness*
  • Irregular Heartbeat*
  • Sinus Trouble*
  • Blood Disease*
  • Frequent Cough*
  • Kidney Problems*
  • Spina Bifida*
  • Breathing Problem*
  • Frequent Diarrhea*
  • Leukemia*
  • Stomach/Intest. Disease*
  • Blood Transfusion*
  • Frequent Headaches*
  • Liver Disease*
  • Stroke*
  • Bruise Easily*
  • Genital Herpes*
  • Low Blood Pressure*
  • Swelling of Limbs*
  • Cancer*
  • Glaucoma*
  • Lung Disease*
  • Thyroid Disease*
  • Chemotherapy*
  • Hay Fever*
  • Mitral Valve Prolapse*
  • Tonsillitis*
  • Chest Pains*
  • Heart Attack/Failure*
  • Osteoporosis*
  • Tuberculosis*
  • Cold Sores/Fever Blisters*
  • Heart Murmur*
  • Pain In Jaw Joints*
  • Tumors or Growths*
  • Congenital Heart Disease*
  • Heart Pacemaker*
  • Parathyroid Disease*
  • Ulcers*
  • Convulsions*
  • Heart Trouble/Disease*
  • Psychiatric Care*
  • Venereal Disease*
  • Yellow Jaundice*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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 my medical status.

  • You will sign this form at your office visit.

    After clicking submit,  you will see a message either confirming  the submission  or  indicating  you have forgotten a required field.  If you forgot a field, finish that question  and select submit again. 
  • Should be Empty: