Medical History

Name * Email *  
Although dental personnel primarily treat the area in and around your mouth, 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? If yes, please explain
Have you ever been hospitalized or had a major operation? If yes, please explain
Have your ever had a serious head or neck injury? If yes, please explain
Are you taking any medications, pill or drugs? If yes, please explain
Do you take, 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
Pregnant/Trying to get pregnant?   Taking oral contraceptives?   Nursing?  
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics  
Other If yes, please explain
Do you have, or have you had, any of the following?
AIDS/HIV Positive Cortisone Medicine Hemophilia Renal Dialysis
Alzheimer's Disease Diabetes Hepatitis A Rheumatic Fever
Anaphylaxis Drug Addiction Hepatitis B or C Rheumatism
Anemia Easily Winded Herpes Scarlet Fever
Angina Emphysema High Blood Pressure Shingles
Arthritis/Goout Epilepsy or Seizures Hives or Rash Sickle Cell Disease
Artificial Heart Valve Excessive Bleeding Hypoglycemia Sinus Trouble
Artificial Joint Excessive Thirst Irregular Heartbeat Spina Bifida
Asthma Fainting Spells/Dizziness Kidney Problems Stomach/Intestinal Disease
Blood Disease Frequent Cough Leukemia Stroke
Blood Transfusion Frequent Diarrhea Liver Disease Swelling of Limbs
Breathing Problem Frequent Headaches Low Blood Pressure Thyroid Disease
Bruise Easily Genital Herpes Lung Disease Tonsillitis
Cancer Glaucoma Mitral Valve Prolapse Tuberculosis
Chemotherapy Hay Fever Pain in Jaw Joints Tumors or Growths
Chest Pains Heart Attack/Failure Parathyroid Care Ulcers
Cold Sores/Fever Blisters Heart Murmur Psychiatric Care Venereal Disease
Congenital Heart Disorder Heart Pace Marker Radiation Treatments Yellow Jaundice
Convulsions Heart Trouble/Disease Recent Weight Loss      

Have you ever had any serious illness not listed above? If yes, please explain:      
Comments:
To the best of may 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 medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN