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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 :