Medical History Patient * DOB * Primary Care Physician Have you ever been hospitalized or had a major operation? * Yes No If yes: * Have you ever had a serious head or neck injury? * Yes No If yes: * Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? * Yes No Do you use tobacco/Vape? * Yes No If yes, how often? * Medications 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 OtherOther Do you have or have you had, any of the following? AID/HIV Positive Cortisone Hemophilia Radiation Treatments Alzheimer’s Diabetes Hepatitis A Drug Addiction Hepatitis B or C Renal Dialysis Anemia Herpes Rheumatic fever Angina Emphysema High Blood Pressure Arthritis/Gout Epilepsy/Seizures Cholesterol Scarlet Fever Excessive Bleeding Hive/Rash Shingles Artificial Joint Hypoglycemia Sickle Cell Asthma Sinus Trouble Blood Disease Kidney Problems Blood Transfusion Leukemia Stomach/Intestinal Problem Frequent Headaches Liver Disease Stroke Bruise Easily Low Blood Pressure Cancer Chemotherapy Glaucoma Lung Disease Thyroid Disease Osteoporosis Hay Fever Mitral Valve Prolapse Heart Attack Pain in Jaw Joints Tuberculosis Cold Sores Heart Murmur Parathyroid Disease Tumor/Growths Congenital Heart Disorder Pacemaker Psychiatric Care Ulcers Heart Valve Replacement A-Fib Anything not listedAnything not listed Signature * signature keyboard Clear Date * 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 health. It is my responsibility to inform the dental office of any changes in medical status. If you are human, leave this field blank. Submit
