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Lawrence Dental Solutions


  Last name

  Mid name

  First name

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.
Please list any current health and wellness providers (e.g., GPs, Specialists, Nutritionists, Therapists)
Name Service Provided Phone Number
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()- -
()- -
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Have you ever been hospitalized or had a major operation? Yes No
If yes,Explain:
Have you ever had a serious head or neck injury? Yes No
If yes, Explain:
Do you take, or have you taken, Phen-Fen or Redux? Yes No
Are you on a special diet? Yes No
Do you use tobacco? Yes No
Do you drink alcohol? Yes No
Do you use controlled substances? Yes No
Height: Weight:
Women: Are you:
Pregnant/Trying to get pregnant? Yes No
Taking oral contraceptives? Yes No
Nursing? Yes No
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Other
If yes, Explain:
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
CPAP/BiPAP
Daytime Sleepiness
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
Grind Teeth
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
Herpes
High Blood pressure
Hives or Rash
Hypoglycemia
Irregular heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Obstructive Sleep Apnea
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sleeping Problems
Sinus Trouble
Snoring
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Ulcers
Tumors or Growths
Venereal Disease

Have you ever had any serious illness not listed above? Yes No
If yes,Explain:
* 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.)