Get Medical History Form

MEDICAL HISTORY PATIENT NAME Birth Date 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. Yes Are you on a special diet Do you use tobacco Do you use controlled substances Women Are you Pregnant/Trying to get pregnant No Have you ever had a serious head or neck injury Are you taking any medications pills or drugs Do you take or have you taken Phen-Fen or Redux Have you ever taken or any other medications containing bisphosphonates Are you under a physician s care now Have you ever been hospitalized or had a major operation If yes please explain Taking oral contraceptives Nursing Are you allergic to any of the following Aspirin Other Codeine Local Anesthetics Metal Acrylic Latex Sulfa drugs AIDS/HIV Positive Alzheimer s Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice 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. MEDICAL HISTORY PATIENT NAME Birth Date 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. Yes Are you on a special diet Do you use tobacco Do you use controlled substances Women Are you Pregnant/Trying to get pregnant No Have you ever had a serious head or neck injury Are you taking any medications pills or drugs Do you take or have you taken Phen-Fen or Redux Have you ever taken or any other medications containing bisphosphonates Are you under a physician s care now Have you ever been hospitalized or had a major operation If yes please explain Taking oral contraceptives Nursing Are you allergic to any of the following Aspirin Other Codeine Local Anesthetics Metal Acrylic Latex Sulfa drugs AIDS/HIV Positive Alzheimer s Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice 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.