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Willow Point Dental P.C.

*Patient Name :

Last name

Mid name

First name

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.

Medical History

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

If Yes, Please Explain:

Have you ever taken Fosamax, Boriva, Actonel or any other medications containing bisphosphonates?

Yes No

If Yes, Please Explain:

PLEASE BRING A COMPLETE LIST OF ALL YOUR MEDICATIONS TO YOUR APPOINTMENT.

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?

Aspirin

Penicillin

Codeine

Local Anesthetics

Acrylic

Metal

Latex

Sulfa Drugs

Other

If Other, Please Explain:

Have you ever had any serious illness not listed above?

Yes No

If Yes, Please List:

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 :		Date :
(Your digital signature (full name) is as legally binding as a physical signature.)