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 physcian's care now?Yes
Have you ever been hospitalized or had a major operation?Yes
Have you ever had a serious head or neck injury?Yes
Are you taking medications, pills, or drugs?Yes
Do you take, or have taken, Phen-Fen or ReduxYes
Are you on a special diet?Yes
Do you use tobacco?Yes

Do you use controlled substances?Yes

Woman: Are You
Pregnent/Trying to get pregnant?Yes
Taking oral contraceptives?Yes
Nursing?Yes
Are you allergic to any of the following? Please check any that apply
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Other
Do you have, or have had, any of the following?

Aids/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Angina
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congential Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Hearbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
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
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaudice
Have you ever had any serious illness not listed above?Yes
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.


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