Medical History

Medical History
Patient Name

Patient's First NamePatient's Last Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
Are you under a physician's care now?
If yes
Have you ever been hospitalized or had a major operation?
If yes
Have you ever had a serious head or neck injury?
If yes
Are you taking any medications, pills, or drugs?
If yes
Do you take, or have you taken, Phen-Fen or Redux?
If yes
Have you ever taken Fosamax, Bonlva, Actonel or any other medications containing bisphosphonates?
If yes
Are you on a special diet?
Have you been diagnosed with sleep apnea?
Do you use tobacco?
Have you been told you snore?
Women: Are you
Are you allergic to any of the following?

Other
Do you use controlled substances?
If yes
Do you have, or have you had, any of the following?
Have you ever had any serious illness not listed?
If yes
Comments
Emergency Name & Phone Number
Emergency Name
Emergency Phone
Please enter a valid phone number.Format: (000) 000-0000.
To the best of my knowledge, the questions on this form have been accuratety 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 of Patient, Parent or Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Emergency Name & Phone Number