Medical History Form 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 Comments Features ServicesDental Services Web Video Ask the Doctor Blog
