Click on Calendar, type the year "YYYY" and pick the month & date.

Medical History

Please note that it is important to fill in all the fields before submitting. Thank you.
*Last name :
Middle name : *First name :
*Your birthday :

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.

Do you have a primary care physician? Yes No *
Do you see a specialist(s)?    Yes No *
Have you been hospitalized or had a major operation in the last 10 years?    Yes No *
Are you taking any prescribed medications, over-the-counter pills, or supplements? Yes No *
Has an immediate family member been diagnosed with diabetes or had a heart attack or stroke? Yes No *
Do you snore? Yes No *
Have you been told that you have sleep apnea? If Yes, what have you been recommended to do? Yes No *
Have you ever taken Fosomax, Boniva, Actonel or any other medications containing biophosphonates? Yes No *
Do you use tobacco or marijuana? Yes No *
Do you use any premedication or anti-anxiety medications for dental treatment? Yes No *
Do you use controlled substances? Yes No *

For women :
Pregnant/Trying to get pregnant    Weeks #:
Are you nursing
Taking oral contraceptives

Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic Sulfa Drugs Metal Latex
Local Anesthetics Other If other, please explain
Do you have, or have you had any of the following?
AIDS/HIV Positive Yes No *
Alzheimer's Disease Yes No *
Anaphylaxis Yes No *
Anemia Yes No *
Angina Yes No *
Arthritis/Gout Yes No *
Artificial Heart Valve Yes No *
Hypoglycemia Yes No *
Blood Disease Yes No *
Stomach/Intestinal Disease Yes No *
Stroke Yes No *
Glaucoma Yes No *
Hay Fever Yes No *
Osteoporosis Yes No *
Ulcers Yes No *
Acid Reflux Yes No *
Cortisone Medicine Yes No *
Diabetes Yes No *
Drug Addiction Yes No *
Easily Winded Yes No *
Emphysema Yes No *
Epilepsy or Seizures Yes No *
Excessive Bleeding Yes No *
Asthma Yes No *
Kidney Problems Yes No *
Breathing Problems Yes No *
Bruise Easily Yes No *
Lung Disease Yes No *
Mitral Valve Prolapse Yes No *
Tuberculosis Yes No *
Convulsions Yes No *
Artificial Stent or Shunt Yes No *
Hemophilia Yes No *
Hepatitis A Yes No *
Hepatitis B or C Yes No *
Herpes Yes No *
High Blood Pressure Yes No *
High Cholesterol Yes No *
Hives or Rash Yes No *
Fainting Spells/Dizziness Yes No *
Blood Transfusion Yes No *
Frequent Headaches Yes No *
Low Blood Pressure Yes No *
Thyroid Disease Yes No *
Chest Pains Yes No *
Tumors or Growths Yes No *
Heart Trouble/Disease Yes No *
HPV Yes No *
Radiation Treatment Yes No *
Recent Weight Loss Yes No *
Renal Dialysis Yes No *
Rheumatic Fever Yes No *
Rheumatism Yes No *
Scarlet Fever Yes No *
Joint Replacement Yes No *
Sinus Trouble Yes No *
Leukemia Yes No *
Liver Disease Yes No *
Cancer Yes No *
Chemotherapy Yes No *
Heart Attack/Failure Yes No *
Heart Pacemaker Yes No *
Psychiatric Care Yes No *

Have you ever had any serious illness not listed above?    Yes No *

* 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 :