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 dental care you will receive. Thank you for answering the following questions.
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Patient name *

 
Birth date

 
Physician

 
Are you under a physician's care now? *

     
 
If yes, please explain:

 
Hospitalization / Major Operation

 
Have you ever been hospitalized or had a major operation? *

     
 
If yes, please explain:

 
Head or neck injury

 
Have you ever had a serious head or neck injury? *

     
 
If yes, please explain

 
Medication

 
Are you taking any medications, pills, or drugs? *

     
 
If yes, please explain

 
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? *


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

 
Check the condition(s) that apply to you


 
Check the condition(s) that apply to you


 
Check the condition(s) that apply to you


 
Other serious illness

 
Have you ever had any serious illness not listed above? *

     
 
If yes, please explain:

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