Medical History

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.

Are you under a physician's care now?
Yes No  
Have you ever been hospitalized or had a major operation?
Yes No  
Have you ever had a serious head or neck injury?
Yes No  
Are you taking any medications, pills, or drugs?
Yes No  
Do you take, or have you taken, Phen-Fen or Redux?
Yes No  
Do you take, or have you taken, Fosmax, Boniva, Actonel, or other medication containing bisphosphonates?
Yes No  
Are you on a special diet?
Yes No  
Do you use tobacco?
Yes No  
Do you use controlled substances?
Yes No  
Are you pregnant, or trying to get pregnant?
Yes No  
Are you taking any oral contraceptives
Yes No  
Are you nursing?
Yes No  

Are you allergic to any of the following?

Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Sulfa
Other

Do you have, or have you had, any of the following?

AIDS/HIV Positive Hemophilia
Alzheimer's Disease Hepatitis A
Anaphylaxis Hepatitis B or C
Anemia Herpes
Angina High Blood Pressure
Arthritis/Gout Hives or Rash
Artificial Heart Valve* Hypoglycemia
Artificial Joint* Irregular Heartbeat
Asthma Kidney Problems
Blood Disease Leukemia
Blood Transfusion Liver Disease
Breathing Problem Low Blood Pressure
Bruise Easily Lung Diseases
Cancer Mitral Valve Prolapse*
Chemotherapy Pain in Jaw Joints
Chest Pains Parathyroid Disease
Cold Sore/Fever Blisters Psychiatric Care
Congenital Heart Disorder Radiation Treatments
Convulsions Recent Weight Loss
Cortisone Medicine Renal Dialysis
Diabetes Rheumatic Fever*
Drug Addiction Rheumatism
Easily Winded Scarlet Fever
Emphysema Shingles
Epilepsy or Seizures Sickle Cell Disease
Excessive Bleeding Sinus Trouble
Excessive Thirst Spina Bifida
Fainting Spells/Dizziness Stomach/Intestinal Disease
Frequent Cough Stroke
Frequent Diarrhea Swelling of Limbs
Frequent Headaches Thyroid Disease
Genital Herpes Tonsillitis
Glaucoma Tubercolosis
Hay Fever Tumors or Growths
Heart Attack/Failure Ulcers
Heart Murmur* Venereal Disease
Heart Pace Maker* Yellow Jaundice
Heart Trouble/Disease Osteoporosis
High Cholesterol  

* Condition may require medication

Have you ever had any serious illness not listed above?
Yes No  
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