Medical History

Name *
Name
Are you under a physician's care now? *
Have you ever been hospitalized or had a major operation? *
Have you ever had a serious head or neck injury? *
Are you taking in medications, pills, or drugs? *
Do you take, or have you taken, Phen-fen or Redux? *
Have you ever taken Fosamax, Boniva, Actonel, or any other medication containing bisphosphonates? *
Do you have a special diet?
Do you use tobacco?
Women: Are you...
Are you allergic to any of the following?
Do you use controlled substances?
Do you have, or have 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 Problems *
Bruise Easily *
Cancer *
Chemotherapy *
Chest Pains *
Cold Sores/Fever Blisters *
Congenital Heart Disorder *
Convulsions *
Cortisone Medicine *
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 *
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 *
Tonsilitis *
Tuberculosis *
Tumors or Growths *
Ulcers *
Venereal Disease *
Yellow Jaundice *
Have you ever had any illness not listed? *
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office in any changes in medical history.
Signature of Patient, Parent or Guardian *
Signature of Patient, Parent or Guardian
Today's Date *
Today's Date