Medical History Form PhoneThis field is for validation purposes and should be left unchanged.Name* First Last Name of Primary Care Physician:*Have you ever been hospitalized or had a major operation?* Yes No If yes, explain:Have you ever had a serious head or neck injury?* Yes No If yes, explain:List the medications you are taking:*Do you take, or have you taken, Phen-Fen or Redux?* Yes No If yes, which?Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?* Yes No If yes, which?Are you on a special diet?* Yes No If yes, explain:Do you use tobacco?* Yes No Do you use controlled substances?* Yes No If yes, explain:Sex Male Female Women: Are you...* Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives? None of the above Are you allergic to any of the following?* Aspirin Penicillin Codeine Acryic Metal Latex Sulfa Drugs Local Anesthetics No Allergies Other? If Other, explain:Do you have, or have you had, any of the following?* AIDS/HIV Postive Alzheimer's Disease Anaphlaxis Anemia Angina Arthritis/Gout 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 Thirts 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 None Apply Have you ever had a serious illness not listed above?* Yes No If yes, explain:CommentsTo 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.Signature of Patient, Parent or Guardian*Date*
