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Medical History

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


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

AIDS/HIV Positive
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Anaphylaxis
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Angina
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Artificial Heart Valve
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Asthma
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Blood Transfusion
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Bruise Easily
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Chemotherapy
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Cold Sores/Fever Blisters
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Convulsions
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Diabetes
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Easily Winded
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Epilepsy or Seizures
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Excessive Thirst
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Frequent Cough
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Frequent Headaches
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Glaucoma
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Heart Attack/Failures
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Heart Pace Maker
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Hemophilia
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Hepatitis B or C
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High Blood Pressure
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Hypoglycemia
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Kidney Problems
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Liver Disease
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Lung Disease
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Pain in Jaw Joints
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Psychiatric Care
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Recent Weight Loss
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Rheumatic Fever
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Scarlet Fever
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Sickle Cell Disease
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Spina Bifida
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Stroke
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Thyroid Disease
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Tuberculosis
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Ulcers
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Yellow Jaundice
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Alzheimer's Disease
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Anemia
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Arthritis/Gout
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Artificial Joint
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Blood Disease
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Breathing Problem
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Cancer
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Chest Pains
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Congenital Heart Disorder
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Coritone Medicine
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Drug Addiction
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Emphysema
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Excessive Bleeding
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Fainting Spells/Dizziness
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Frequent Diarrhea
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Genital Herpes
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Hay Fever
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Heart Murmur
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Heart Trouble/Disease
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Hepatitis A
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Herpes
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Hives or Rash
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Irregular Heartbeat
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Leukemia
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Low Blood Pressure
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Mitral Valve Prolapse
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Osteoporosis
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Parathyroid Disease
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Radiation Treatments
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Renal Dialysis
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Rheumatism
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Shingles
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Sinus Trouble
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Stomach/Intestinal Disease
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Swelling of Limbs
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Tonsilitis
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Tumors or Growths
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Venereal Disease
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Have you ever had any serious illness not listed above?
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If yes, please explain:
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