Form:
Health History
Page 1
Page 2
Confirm
Patient Information
FIRST Name
LAST Name
MI
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?
YES
NO
Have you ever been hospitalized or had a major operation?
YES
NO
Have you ever had a serious head or neck injury?
YES
NO
Are you taking any medications pills or drugs?
YES
NO
Do you take or have you taken Phen-Fen or Redux?
YES
NO
Have you ever taken Fosamax Boniva Actonel or any other medications containing bisphosphonates?
YES
NO
Are you on a special diet?
YES
NO
Do you use tobacco?
YES
NO
Women: Are you...
Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?
I’ve checked all above that apply
*
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
I’ve checked all above that apply
*
Other?
Do you use controlled substances?
YES
NO
NEXT
