Essential Medical History for Comprehensive Dental Care

Please complete the Medical History form to provide us with important health information, enabling our team to deliver safe, personalized, and effective dental care tailored to your specific needs.

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Medical History

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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?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?

Women: Are you

Pregnant/Trying to get pregnant?(Required)
Taking oral contraceptives?(Required)
Nursing?(Required)

Are you allergic to any of the following?

Do you have, or have you had, any of the following?
AIDS/HIV Positive
Cortisone Medicine
Hemophilia
Radiation Treatments
Alzheimer’s Disease
Diabetes
Hepatitis A
Recent Weight Loss
Anaphylaxis
Drug Addiction
Hepatitis B or C
Renal Dialysis
Anemia
Easily Winded
Herpes
Rheumatic Fever
Angina
Emphysema
High Blood Pressure
Rheumatism
Arthritis/Gout
Epilepsy or Seizures
High Cholesterol
Scarlet Fever
Artificial Heart Valve
Excessive Bleeding
Hives or Rash
Shingles
Artificial Joint
Excessive Thirst
Hypoglycemia
Sickle Cell Disease
Asthma
Fainting Spells/Dizziness
Irregular Heartbeat
Sinus Trouble
Blood Transfusion
Frequent Cough
Kidney Problems
Spina Bifida
Blood Disease
Frequent Diarrhea
Leukemia
Stomach/Intestinal Disease
Breathing Problem
Frequent Headaches
Liver Disease
Stroke
Bruise Easily
Genital Herpes
Low Blood Pressure
Swelling of Limbs
Cancer
Glaucoma
Lung Disease
Thyroid Disease
Chemotherapy
Hay Fever
Mitral Valve Prolapse
Tonsillitis
Chest Pains
Heart Attack/Failure
Osteoporosis
Tuberculosis
Cold Sores/Fever Blisters
Heart Murmur
Pain in Jaw Joints
Tumors or Growths
Congenital Heart Disorder
Heart Pacemaker
Parathyroid Disease
Ulcers
Convulsions
Heart Trouble/Disease
Convulsions
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed above?
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.
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