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.

Name:

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 neck or head 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

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 Acrylic

 Metal Latex Local Anesthetics Other

If yes, 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

Artificial Joint

 Yes No

Asthma

 Yes No

Blood Disease

 Yes No

Blood Transfusion

 Yes No

Breathing Problem

 Yes No

Bruise Easily

 Yes No

Cancer

 Yes No

Chemotherapy

 Yes No

Chest Pains

 Yes No

Cold Sores/Fever Blisters

 Yes No

Congenital Heart Disorder

 Yes No

Convulsions

 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

Excessive Thirst

 Yes No

Fainting Spells/Dizziness

 Yes No

Frequent Cough

 Yes No

Frequent Diarrhea

 Yes No

Frequent Headaches

 Yes No

Genital Herpes

 Yes No

Glaucoma

 Yes No

Hay Fever

 Yes No

Heart Attack/Failure

 Yes No

Heart Murmur

 Yes No

Heart Pace Maker

 Yes No

Heart Trouble/Disease

 Yes No

Hemophilia

 Yes No

Hepatitis A

 Yes No

Hepatitis B or C

 Yes No

Herpes

 Yes No

High Blood Pressure

 Yes No

Hives or Rashes

 Yes No

Hypoglycemia

 Yes No

Irregular Heartbeat

 Yes No

Kidney Problems

 Yes No

Leukemia

 Yes No

Liver Disease

 Yes No

Low Blood Pressure

 Yes No

Lung Disease

 Yes No

Mitral Valve Prolapse

 Yes No

Pain in Jaw Joints

 Yes No

Parathyroid Disease

 Yes No

Psychiatric Care

 Yes No

Radiation Treatments

 Yes No

Recent Weight Loss

 Yes No

Renal Dialysis

 Yes No

Rheumatic Fever

 Yes No

Rheumatism

 Yes No

Scarlet Fever

 Yes No

Shingles

 Yes No

Sickle Cell Disease

 Yes No

Sinus Trouble

 Yes No

Spina Bifida

 Yes No

Stomach/Intestinal Disease

 Yes No

Stroke

 Yes No

Swelling of Limbs

 Yes No

Thyroid Disease

 Yes No

Tonsilitis

 Yes No

Tubercolosis

 Yes No

Tumors or Growths

 Yes No

Ulcers

 Yes No

Venereal Disease

 Yes No

Yellow Jaundice

 Yes No

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

If yes, please explain:

Comments:

To the best of my knowledge, the questions on this form have been correctly answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.