Medical History

Medical History

Name: Birth Date

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?	YesNo Invalid Input	If yes, please explain:	Invalid Input
Have you ever been hospitalized or had a major operation?	YesNo Invalid Input	If yes, please explain:	Invalid Input
Have you ever had a serious head or neck injury?	YesNo Invalid Input	If yes, please explain:	Invalid Input
Are you taking any medications, pills, or drugs?	YesNo Invalid Input	If yes, please explain:	Invalid Input
Do you take, or have you taken, Phen-Fen or Redux?	YesNo Invalid Input	If yes, please explain:	Invalid Input
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?	YesNo Invalid Input	If yes, please explain:	Invalid Input
Are you on a special diet?	YesNo Invalid Input	If yes, please explain:	Invalid Input
Do you use tobacco?	YesNo Invalid Input
Do you use controlled substances?	YesNo Invalid Input
Women:
Are you pregnant or trying to get pregnant?	YesNo Invalid Input
Nursing?	YesNo Invalid Input
Taking Oral Contraceptives?	YesNo Invalid Input
Are you allergic to any of the following?	AspirinPenicillinCodieneAcrylicMetalLatexLocal AnestheticsOther Invalid Input
If yes, please explain::

Do you have, or have you ever had, any of the following?

AIDS/HIV Positive	YesNo Invalid Input
Anaphylaxis	YesNo Invalid Input
Angina	YesNo Invalid Input
Artificial Heart Valve	YesNo Invalid Input
Asthma	YesNo Invalid Input
Blood Transfusion	YesNo Invalid Input
Bruise Easily	YesNo Invalid Input
Chemotherapy	YesNo Invalid Input
Cold Sores/Fever Blisters	YesNo Invalid Input
Convulsions	YesNo Invalid Input
Diabetes	YesNo Invalid Input
Easily Winded	YesNo Invalid Input
Epilepsy or Seizures	YesNo Invalid Input
Excessive Thirst	YesNo Invalid Input
Frequent Cough	YesNo Invalid Input
Frequent Headaches	YesNo Invalid Input
Glaucoma	YesNo Invalid Input
Heart Attack/Failures	YesNo Invalid Input
Heart Pace Maker	YesNo Invalid Input
Hemophilia	YesNo Invalid Input
Hepatitis B or C	YesNo Invalid Input
High Blood Pressure	YesNo Invalid Input
Hypoglycemia	YesNo Invalid Input
Kidney Problems	YesNo Invalid Input
Liver Disease	YesNo Invalid Input
Lung Disease	YesNo Invalid Input
Pain in Jaw Joints	YesNo Invalid Input
Psychiatric Care	YesNo Invalid Input
Recent Weight Loss	YesNo Invalid Input
Rheumatic Fever	YesNo Invalid Input
Scarlet Fever	YesNo Invalid Input
Sickle Cell Disease	YesNo Invalid Input
Spina Bifida	YesNo Invalid Input
Stroke	YesNo Invalid Input
Thyroid Disease	YesNo Invalid Input
Tuberculosis	YesNo Invalid Input
Ulcers	YesNo Invalid Input
Yellow Jaundice	YesNo Invalid Input

Alzheimer's Disease	YesNo Invalid Input
Anemia	YesNo Invalid Input
Arthritis/Gout	YesNo Invalid Input
Artificial Joint	YesNo Invalid Input
Blood Disease	YesNo Invalid Input
Breathing Problem	YesNo Invalid Input
Cancer	YesNo Invalid Input
Chest Pains	YesNo Invalid Input
Congenital Heart Disorder	YesNo Invalid Input
Coritone Medicine	YesNo Invalid Input
Drug Addiction	YesNo Invalid Input
Emphysema	YesNo Invalid Input
Excessive Bleeding	YesNo Invalid Input
Fainting Spells/Dizziness	YesNo Invalid Input
Frequent Diarrhea	YesNo Invalid Input
Genital Herpes	YesNo Invalid Input
Hay Fever	YesNo Invalid Input
Heart Murmur	YesNo Invalid Input
Heart Trouble/Disease	YesNo Invalid Input
Hepatitis A	YesNo Invalid Input
Herpes	YesNo Invalid Input
Hives or Rash	YesNo Invalid Input
Irregular Heartbeat	YesNo Invalid Input
Leukemia	YesNo Invalid Input
Low Blood Pressure	YesNo Invalid Input
Mitral Valve Prolapse	YesNo Invalid Input
Osteoporosis	YesNo Invalid Input
Parathyroid Disease	YesNo Invalid Input
Radiation Treatments	YesNo Invalid Input
Renal Dialysis	YesNo Invalid Input
Rheumatism	YesNo Invalid Input
Shingles	YesNo Invalid Input
Sinus Trouble	YesNo Invalid Input
Stomach/Intestinal Disease	YesNo Invalid Input
Swelling of Limbs	YesNo Invalid Input
Tonsilitis	YesNo Invalid Input
Tumors or Growths	YesNo Invalid Input
Venereal Disease	YesNo Invalid Input

Have you ever had any serious illness not listed above?	YesNo Invalid Input
If yes, please explain:	Invalid Input

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