MEDICAL HISTORY FORM

Patient's Name*

First Last

Patient's Birthdate*

Patient's Email*

Date Created*

Medical History

Are you under a physician's care now?*

If yes, what is that physician's name?*

Have you ever been hospitalized or had a major operation?*

Is yes, for what were you hospitalized/operated on?*

Have you ever had a serious head or neck injury?*

If yes, what was the injury/injuries?*

Are you taking any medications, pills, or drugs?*

If yes, what are the medications/pills/drugs?*

Do you take, or have you taken Phen-Fen or Redux?*

If yes, then which?*

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?*

If yes, then what was the medication?*

Do you use tobacco?*

Do you use controlled substances?*

Is yes, then what are the substances?*

Have you been vaccinated for Covid-19?*

Women: Are you...

Pregnant/trying to get pregnant?
Nursing?
Taking oral contraceptives?

Allergies

Are you allergic to any of the following?

Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
Other(s)

Other Allergy/Allergies*

Previous Illnesses

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

Have you ever had any serious illness not listed above?

Other Illness/Illnesses*

Other 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 office of any changes in medical status.

Signature of Patient, Parent, or Guardian*

I have thoroughly reviewed the information entered on this page and can confirm that all information is accurate.