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Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is 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.

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:
Are you on a special diet? Yes No    If yes, please explain:
Do you use tobacco? Yes No
Do you use controlled substances? Yes No
   

Women

Are you pregnant or trying to get pregnant? Yes No
Are you nursing? Yes No
Are you taking oral contraceptives? Yes No
   

Allergies

Are you allergic to any of the following? Aspirin Penicillin Codine Acrylic
Metal Latex Local Anesthetics Other
If yes, please explain:
   
Do you have, or have you had, any of the following?
AIDS/HIV Positive Chest Pains Frequent Headaches
Alzheimer's Disease Cold Sores/Fever Blisters Genital Herpes
Anaphylaxis Congenital Heart Disorder Glaucoma
Anemia Convulsions Hay Fever
Angina Cortisone Medication Heart/Attack Failure
Arthritis/Gout Diabetes Heart Murmur
Artificial Heart Valve Drug Addiction Heart Pace Maker
Artificial Joint Easily Winded Heart Trouble/Disease
Asthma Emphysema Hemophilia
Blood Disease Epilepsy or Seizures Hepatitis A
Blood Transfusion Excessive Bleeding Hepatitis B or C
Breathing Problem Excessive Thirst Herpes
Bruise Easily Fainting Spells/Dizziness High Blood Pressure
Cancer Frequent Cough Hives or Rash
Chemotherapy Frequent Diarrhea Hypoglycemia

Irregular Heartbeat Scarlet Fever
Kidney Problems Shingles
Leukemia Sickle Cell Disease
Liver Disease Sinus Trouble
Low Blood Pressure Spina Bifida
Lung Disease Stomach/Intestinal Disease
Mitral Valve Prolapse Stroke
Pain in Jaw/Joints Swelling of Limbs
Parathyroid Disease Thyroid Disease
Psychiatric Care Tonsilitis
Radiation Treatments Tuberculosis
Recent Weight Loss Tumors or Growths
Renal Dialysis Ulcers
Rheumatic Fever Venereal Disease
Rheumatism Yellow Jaundice


Have you ever had any serious illness not listed above ? Yes No    If yes, please explain:

   
If you have any other comments please enter them here:
To the best of my nkowledge, the questions on this form have been accurately 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.

 Full name of of Patient, Parent, or Guardian
     Date