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Home
Office Info
About Us
Office Policies & Mission
Map & Directions
Financial & Insurance
Contact Us
Patient Info
First Dentist Appointment
Patient Forms
Dental Health
Brushing & Flossing
Common Dental Problems
Emergency Care
Treatments
Preventive Dentistry
General Treatment
Benefits
Am I a Good Candidate?
FAQs
TMJ / TMD
Dental Crowns
Dentures
Benefits
Am I a Candidate?
Aftercare
Facts
Misconceptions
Dental Implants
Benefits
Am I a Candidate?
FAQs
Aftercare
Facts
Misconceptions
Cosmetic Dentistry
Cosmetic Dentist
Benefits
FAQs
Aftercare
Facts
Misconceptions
Teeth Whitening
Benefits
Am I a Candidate?
FAQs
Porcelain Veneers
Benefits
Who Is a Candidate?
Aftercare
FAQs
Invisalign
Benefits
Am I a Candidate?
FAQs
Aftercare
Traditional Braces
Benefits
FAQs
Sedation Dentistry
Children’s Dentistry
Benefits
FAQs
Endodontics
Benefits
Am I a Candidate?
FAQs
Periodontics
Technology
Smile Gallery
Testimonials
Contact Us
Map & Directions
Patient Satisfaction & Feedback
Blog
Medical History Form
Patient Name
*
Date of Birth
*
Month
Day
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.
Are you under a physician's care now?
*
Yes
No
If yes, please explain:
Have you ever been hospitalized or had a major operation?
*
Yes
No
If yes, please explain:
Have you ever had a serious head or neck injury?
*
Yes
No
If yes, please explain:
Are you taking any medications, pills, or drugs?
*
Yes
No
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?
*
Yes
No
Do you take, or have you taken, Fosamax, Boniva, Actenol or any other medications 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
Women: Are you:
Pregnant/Trying to get pregnant?
Yes
No
Taking oral contraceptives?
Yes
No
Nursing?
Yes
No
Are you Allergic to any of the following? Check all that apply
Aspirin
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa Drugs
Other
If other, please explain:
Do you have, or have you had, any of the following?
Check all that apply
*
Not Applicable
AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Bruise Easily
Breathing Problems
Cancer
Chemotherapy
Chest Pains
Cold sore/Fever blisters
Congenital Heart Disorder
Convulsions
Cortisone medicine
Diabetes
Drug addiction
Easily winded
Emphysema
Epilepsy or seizures
Excessive Bleedings
Excessive thirst
Fainting spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart attack / failure
Heart murmur
Heart pacemaker
Heart trouble / disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High blood pressue
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular heartbeat
Kidney problems
Leukemia
Liver Disease
Low blood pressue
Lung disease
Mitral Valve Prolapse
Osteoporosis
Pain in jaw joints
Parathyroid disease
Psychiatric care
Radiation treatments
Recent weight loss
Renal Dialysis
Rheumatic fever
Rheumatism
Scarlet Fever
Shingles
Sickle cell disease
Sinus trouble
Spina bifida
Stomach / intestinal disease
Stroke
Swelling of limbs
Thyroid disease
Tonsilitis
Tuberculosis
Tumors
Ulcers
Venereal disease
Yellow jaundice
If you have had any serious illness not listed above, please explain below:
Additional Comments:
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 medical status
*
Signature of patient, parent, or guardian:
Date
*
Month
Day
Year