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Medical History Form
Name
First
Last
D.O.B.
MM slash DD slash YYYY
Today's Date
MM slash DD slash YYYY
Are you under a physician's care now?
Yes
No
If Yes Provide Physician's name:
Have you ever been hospitalized or had a major operation?
Yes
No
Please Specify:
Have you ever had a serious head or neck injury?
Yes
No
Please Specify:
Are you taking any medications, pills, or drugs?
Yes
No
Please Specify:
Do you take, or have you taken, Phen-Fen or Redux7
Yes
No
If Yes:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates7
Yes
No
Please Specify:
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Women:
Are you pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
Other
Other Allergies:
Do you use controlled substances?
Yes
No
If Yes:
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxi
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Do 2
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Do 3
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Do 4
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Do 5
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Do 6
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Hives or Rash
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Do 8
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Do 9
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed
Yes
No
If Yes:
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. It is my responsibility to inform the dental office of any changes in medical status.
Your Full Name
Date
MM slash DD slash YYYY
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