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 medications that you may be taking could have an important interrelationship with the
dentistry you will receive. We are here to give you the best treatment possible. Thank you for answering the following questions.
Check all that apply:
Who is your primary care physician and address?
Have you ever been hospitalized or had a major operation, including neck/head injuries? Please explain:
Are you taking any medications, pills, drugs (inc. over the counter, supplements, natural medicines?
Do you take, or have taken Phen-Fen or Redux? Please explain:
Are you on a special diet? Please explain:
Do you use tobacco? Yes
No
Do you drink grapefruit juice? Yes
No
Do you use a controlled substance (inc. recreational drugs or needles)? Yes
No
Women: Are you:
Taking oral contraceptives
Pregnant/Trying to get pregnant?
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Local Anesthetics
Other:
Acrylic
Nursing
Metal
Latex
Do you have, or have you had any of the following? CIRCLE ANY AND ALL THAT APPLY
AIDS/HIV positive
Alzheimer
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Bi-Polar Disorder
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Cholesterol
Chest Pains
Cold Sores/ Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care/Drugs
Radiation Treatment
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Schizophrenia
Shingles
Sickle Cell Disease
Sinus Trouble
Sleep Aids
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Ulcers
Venereal Disease
Have you ever had any serious illness not listed above?
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 health. It is my responsibility to inform this office of any changes.
___________________________________________
Signature of Patient or Guardian
________________________
Date