Patient’s Name *
Birthdate *
Are you under a physician’s care now? * NoYes
If yes:
Have you ever been hospitalized or had a major operation? * NoYes
Have you ever had a serious head or neck injury? * NoYes
Are you taking any medications, pills, or drugs? * NoYes
Do you take, or have you taken, Phen-Fen or Redux? * NoYes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? * NoYes
Are you on a special diet? * NoYes
Do you use tobacco? * NoYes
Do you use controlled substances? * NoYes
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
Other
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 Problems
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
Hemophilia
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
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? NoYes
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 offie of any changes in medical status.
I Agree *
