Medical History Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you. Birth Date: Have you been under the care of a medical doctor during the past two years? Yes No If yes, please explain. Do you take, or have you taken, Phe-n-Fen or Redux? Yes No Have you ever taken Fosamax, Boniva., Acton el or any other medications containing bisphosphonates? Yes No Do you use controlled substances? Yes No Please check yes or no to indicate if you have had any of the following: AIDS/HIV Positive Yes No Alzheimer's Disease Yes No Anaphylaxis Yes No Anemia Yes No Angina Yes No Arhritis/Gout Yes No Artificial Heart Valve Yes No Artificial Joint Yes No Asthma Yes No Blood Disease Yes No Blood Transfusion Yes No Breathing Problems Yes No Bruise Easily Yes No Cancer Yes No Chemotherapy Yes No Chest Pains Yes No Cold Sores/Fever Blisters Yes No Congenital Heart Disorder Yes No Convulsions Yes No Cortisone Medicine Yes No Diabetes Yes No Drug Addiction Yes No Easily Winded Yes No Emphysema Yes No Epilepsy or Seizures Yes No Excessive Bleeding Yes No Excessive Thirst Yes No Fainting Spells/Dizziness Yes No Frequent Cough Yes No Frequent Diarrhea Yes No Frequent Headaches Yes No Genital Herpes Yes No Glaucoma Yes No Hay Fever Yes No Heart Attack/Failure Yes No Heart Murmur Yes No Heart Pacemaker Yes No Heart Trouble/Disease Yes No Hemophilia Yes No Hepatitis A Yes No Hepatitis B or C Yes No Herpes Yes No High Blood Pressure Yes No High Cholesterol Yes No Hives or Rash Yes No Hypoglycemia Yes No Irregular Heartbeat Yes No Kidney Problems Yes No Leukemia Yes No Liver Disease Yes No Low Blood Pressure Yes No Lung Disease Yes No Mitral Valve Prolapse Yes No Osteoporosis Yes No Pain in Jaw Joints Yes No Parathyroid Disease Yes No Psychiatric Care Yes No Radiation Treatments Yes No Recent Weight Loss Yes No Renal Dialysis Yes No Rheumatic Fever Yes No Rheumatism Yes No Scarlet Fever Yes No Shingles Yes No Sickle Cell Disease Yes No Sinus Trouble Yes No Spina Bifida Yes No Stomach/Intestinal Disease Yes No Stroke Yes No Swelling of Limbs Yes No Thyroid Disease Yes No Tonsillitis Yes No Tuberculosis Yes No Tumors or Growths Yes No Ulcers Yes No Venereal Disease Yes No Yellow Jaundice Yes No Allergies: NONE Amoxicillin Aspirin Barbiturates Codeine Epinephrine Erythromycin Keflex Iodine Latex Lortab Morphine Penicillin Sulfa Tetracycline Other List medications currently taking (name and dosage): Do you have or have you had any disease, condition or problem not listed above? Yes No If yes, please explain Do you need to take any antibiotics (pre-medicate) before any dental appointment? Yes No If yes, please explain Have you been in the hospital or had a serious illness within the past five years? Yes No If yes, please explain Women: Are you pregnant? Yes No Are you nursing? Yes No Do you take Birth Control Pills? Yes No To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing icnorrect information can be dangerous to my (or patients) health. It is my responsibility to inform the dental office of any changes in medical status. Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.