MEDICAL HISTORY
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?
YesNo
Have you ever been hospitalized or had a major operation?
YesNo
Have you ever had a serious head or neck injury?
YesNo
Are you taking any medications, pills or drugs?
YesNo
Do you take, or have you taken, Phen-Fen or Redux?
YesNo
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
YesNo
Are you on a special diet?
YesNo
Do you use tobacco?
YesNo
Have you been out of the country within the last 6 months?
YesNo
Are you allergic to the following:
Acrylic
Asprin
Codeine
Dental Anesthetics
Latex
Metals
Penicillin
Sulfa Drugs
Do you use controlled substances?
YesNo
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 Disease
Convulsions
Yellow Jaundice
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy/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 Colesterol
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 Diseaes
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsilitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
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