Medical History

Medical History
Name
What is your estimate of your general health? *
Are you under a physician's care now? *
Have you ever been hospitalized or had a major operation? *
Have you ever had a serious head or neck injury? *
Are you taking any medications, pills, or drugs? *
Do you take, or have you taken, PhenFen or Redux? *
Have you ever taken Fosomax, Boniva, Actonel or any other medications containing biophosphonates? *
Are you on a special diet? *
Do you use tobacco? *
Do you use controlled substances? *
Have you ever been advised that you require antibiotics prior to dental appointment? *
Women (Please check all that apply)
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic) *
If other, please list
Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *

By placing my name and date below: I acknowledge that, 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. Should I have any questions, I can contact the practice at any time.

Today's Date *
Date
Signature *
Use your mouse or finger to draw your signature above
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