Medical History Step 1 of 2 50% PATIENT NAME Birth Date MM slash DD slash YYYY 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 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 If yes, please explain Have you ever had a serious head or neck injury? Yes No If yes, please explain Are you taking and medications, pills, or drugs? Yes No If yes, please explain Do you take, or have you taken, Phen-Fen or Redux? Yes No If yes, please explain Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No If yes, please explain Are you on a special diet? Yes No Do you use tobacco? Yes No Do you use controlled substances? Yes No Women: Are you Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives? Are you allergic to the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Sulfa Drugs If yes, please explain: Do you have, or have 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/Fever Blisters 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 Pacemaker Heart Trouble/disease Hemophelia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever 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 If yes, please explain: Have you ever had any serious illness not listed above? Yes No Comments SIGNATURE OF PATIENT, PARENT, or GUARDIAN 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 changes in my medical status DATE MM slash DD slash YYYY Comments This field is for validation purposes and should be left unchanged.