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OfU=MSNV 3E ISNH SNOIIS] NO'I]V
MEDICAL HISTORY
PATIENT NAME
Birth Date
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may
have, or medication that you may be taking, could have an important intenelationship with the dentistry you will receive. Thank you for answering the
following questions.
now? Yes _ No
) Yes [)' No
Have you ever had a serious head or neck injury? ,.- Yes , No
Are you taking any medications, pills, or drugs? Yes , t No
Do you take, or have you taken, Phen-Fen or Redux? _ Yes - No
Have you ever taken Fosamax, Boniva, Actonel, Zometa or anv .- \, .r ..
t.- No
other medications containing bisphosphonates? ; Yes
Are you under a physician's care
Have you ever been hospitalized or had a major operation?(
Are you on a special diet? (-_) Yes
Do you use tobacco?
(_)
Yes
Do you use controlled substances? Yes
Women: Are you
Pregnant/Trying to get
pregnant? Yes
-
lf yes, please explain:
lf yes, please explain:
lf yes, please explain:
lf yes, please explain:
No
No
No
Taking oral contraceptivesZ
No
(
)
Yes (
)
Nursing? (.
No
.r
Yes
I
.
No
Are you allergic to any of the following?
, Aspirin [] Penicillin
'- Other lf yes, please explain:
I
Codeine fl
Local Anesthetics
-
I
i-
Acrylic
Do you have, or have you had, any of the following?
AIDS/HIV
Positive (l Ves l.-,1 tto
Disease (._) ves (- -; tto
Alzheimer's
Anaphylaxis
..-
Yes
t.-l
No
Anemia
[-] ves i-l tto
Angina
l-) Yes t-) No
Arthritis/Gout
r'-, Yes l-t No
Artificial Heart Valve C) yes () tto
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
l.-) Ves (-r t'lo
i,
,l
Ves
ves
i-) ves
( ) ves
(_) ves
fr tto
f) No
O tto
Problem
t) ruo
Bruise Easily
3 ruo
(-r Yes Q tto
cancer
Chemotherapy C) Yes (--l
- t'to
Yes No
Chest Pains
Cold SoresiFever Blisters
- Yest- No
Yes
No
Congenital Heart Disorder
Convulsions
O Yes (,r t"to
Breathing
Cortisone
Medicine
Diabetes
Drug Addiction
l_) Ves
fj
No
Hemophilia
(-) ves
I
No
Hepatitis A
Hepatitis B or
i_, ves
,])
(-_t tto
t]r tto
Emphysema
| .) No
Epilepsyorseizures (-) Yes !i tto
Excessive Bleeding i.-) Yes l-r No
Excessive Thirst
r-) Ves (-) tlo
Fainting Spells/Dizziness Yes No
FrequentCough ;'l ves (-r tto
Frequent Diarrhea
Ves ., flo
Frequent Headaches (J Ves 3 Uo
Genital Herpes
f; ves ! ruo
l-, ves Q ruo
Glaucoma
Hay Fever
f) ves ij ruo
Heart Attack/Failure Yes No
Heart Murmur
O ves () uo
() Yes Cr No
Heart Pacemaker
Heart Trouble/Disease O Ves O No
Easily Winded
Have you ever had any serious illness not listed
ves
L. ,l ves
above?,1 Yes
f-'
Q
C
-r
Metal
ves '' No
-t ruo
ves Q
i, ruo
[l ves i-l ruo
High Blood Pressure [l ves I tto
High Cholesterol (-) Ves ,,\ flo
Hives or Rash
l-r) Ves L--r t'lo
Herpes
i-1, Yes
O ves f) ruo
O ves Q
- Xo
Kidney Problems
Yes
No
Hypoglycemia
lrregular Heartbeat
Yes l._) No
r_) Yes (- No
.-)
Leukemia
Liver Disease
!) ves Q no
Disease . Yes No
Mitral ValveProlapseQ Yes Q No
Low Blood Pressure
Lung
Osteoporosis
Pain in Jaw Joints
Ll
l]
Q
Yes
Ves
i-)
[)
t]
Care (.] Ves !)
Parathyroid Disease
Psychiatric
Yes
No
No
No
tto
- r Latex
Sulfa drugs
(-
Radiation Treatments
i
Recent Weight Loss
Renal Dialysis
I
-) Yes r. -) No
i.,l Yes
No
Rheumatic Fever
Rheumatism
i_1 ves
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/lntestinal
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or GroMhs
Ulcers
Venereal Disease
Yellow Jaundice
.r Yes
i-r
r.l
ves .-) tto
i.-) ves l--r trto
ves
ruo
(-. Yes (--l xo
,-) ves [,) t'to
!-r ves ] ruo
[]
ir
Disease Yes
i) Yes i_l
GUARDIAN
No
ves i't tto
rl_,r ves (_, tto
i_)r Yes
I
i,'r
Yes l. -)
r-.) Yes r.-'
l.
[]
i) Yes (i-) Yes il
i_^l
ves
No
DATE
No
O
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. lt is my responsibility to inform the dental office of any changes in medical status.
oT
ruo
l-,
Comments:
SIGNATURE OF PATIENT, PARENT,
No
No
No
No
No
No
No