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Name: Birth Date :
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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? Yes No
If yes, please explain:
Have you ever been hospitalized or had a major operation? Yes No
Have you ever had a serious head or neck injury? Yes No
Are you taking any medications, pills, or drugs? Yes No
Do you take, or have you taken, Phen-Fen or Redux? Yes No
Are you on a special diet? Yes No
Do you use tobacco? Yes No
Do you use controlled substances? Yes No
Women: Pregnant/Trying to get pregnant? Yes No
Nursing? Yes No
Taking oral contraceptives? Yes No
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic Metal Latex
Local Anesthetics Other, Please explain:
Do you have, or have you had, any of the following:
AIDS/HIV Positive Alzheimer's Disease
Anaphylaxis Anemia
Angina Arthritis/Gout
Artificial Heart Valve Artificial Joint
Asthma Blood Disease
Blood Transfusion Breathing Problem
Bruise Easily Cancer
Chemotherapy Chest Pains
Cold Sores Congenital Heart Disorder
Convulsions Cortisone Medicine
Diabetes Drug Addiction
Easily Winded Emphysema
Epilepsy or Seizures Excessive Bleeding
Excessive Thirst Fainting Spells/Dizziness
Frequent Cough Frequent Diarrhea
Frequent Headaches Genital Herpes
Glaucoma Hay Fever
Heart Attack/Failure Heart Murmur
Heart Pace Maker Heart Trouble/Disease
Hemophilia Hepatitis A
Hepatitis B or C Herpes
High Blood Pressure Hives or Rash
Hypoglycemia Irregular Heartbeat
Kidney Problems Leukemia
Liver Disease Low Blood Pressure
Lung Disease Mitral Valve Prolapse
Pain in Jaw Joints Parathyroid Disease
Psychiatric Care Radiation Treatments
Recent Weight Loss Renal Dialysis
Rheumatic Fever Rheumatism
Scarlet Fever Shingles
Sickle Cell Disease Sinus Trouble
Spina Bifida Stomach/Intestinal Disease
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 above? Yes No
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.
By entering the last four (4) digits of you social security number and clicking the Submit button below you agree to the statement above.
Last four digits of your social security number: Date:
