Medical History

PARENT NAME Birth Day

Although dental personael 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 talking, 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 talking any medications, pills, or drugs?  Yes No   If yes, please explain:

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: 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 Local Anesthetics

 Other    If yes, please explain:

 

Do you have, or have you had, any of the following?

 AIDS/HIV Positive Chest Pains Frequent Headaches Irregular Heartbeat Scarlet Fever Alzheimer's Disease Cold Sores/Fever Blisters Genltal Herpes Kidney Problems Shingles Anaphylaxis Congenltal Heart Disorder Glaucoma Leukemia Sickle Cell Disease Anemla Convuisions Hay Fever Liver Disease Sinus Trouble Angina Cortisone Medicine Heart Attrack/Failure Low Blood Pressure Spina Bifida Arthritis/Gout Diabetes Heart Murmur Lung Disease Stomach/Intestinal Disease Artificial Heart Valve Drug Addiction Heart Pace Maker Mitral Valve Prolapse Stroke Artificial Joint Easily Winded Heart-Trouble/Disease Pain in Jaw Joints Swelling of Limbs Asthma Emphysema Hemophilia Parathyroid Disease Thyroid Disease Blood Disease Epilepsy or Seizures Hepatitis A Psychiatric Care Tonsillitis Blood Transfusion Excessive Bleeding Hepatitis B or C Radiation Treatments Tuberculosis Breathing Problem Excessive Thirst Herpes Recent Weight Loss Tumors or Growths Bruise Easily Fainting Spells/Dizziness High Blood Pressure Renal Dialysis Ulcers Cancer Frequent Cough Hives of Rash Rheumatic Fever Venereal Disease Chemothoerapy Frequent Diarrhea Hypogiycemia Rheumatism Yellow Jaundice

Have you ever had any serious illness not listed above?  Yes No   If yes, please explain:

Comments:

To the best of my knowledge, the questions on this form have been accurafely 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.


SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE