Ranger Dental
Medical History
Patient Name_____________________________________ Birth Date__________________
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 relationship with the dentistry you will receive. Thank you for answering the
following questions.
Are you under a physician’s care now?
Have you ever been hospitalized or had a major operation?
Have you ever been in a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken, Fosamax, Boniva, Actonel or any
Other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Women: Are you:
Pregnant/Trying to get pregnant?
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
If yes, please explain:_______________________________________
If yes, please explain:_______________________________________
If yes, please explain:_______________________________________
If yes, please explain:_______________________________________
________________________________________________________
________________________________________________________
Taking oral contraceptives?
Yes
No
Nursing?
Yes
No
Are you allergic to any of the following?
Aspirin
Other
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa drugs
If yes, please explain:____________________________________________________________________________________________
Do you have, or have you had, any of the following?
Mark
Yes
Aids/HIV Positive
____
Alzheimer’s Disease
____
Anaphylaxis
____
Anemia
____
Angina
____
Arthritis/Gout
____
Artificial Heart Valve
____
Artificial Joint
____
Asthma
____
Blood Disease
____
Blood Transfusion
____
Breathing Problems
____
Bruise Easily
____
Cancer
____
Chemotherapy
____
Chest Pains
____
Cold Sores/Fever Blisters ____
Congenital Heart Disorder ____
Convulsions
____
No
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Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Have you ever had any serious illness not listed above?
Yes
Yes
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No
No
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Yes
No
Hemophilia
____ ____ Radiation Treatments
Hepatitis A
____ ____ Recent Weight Loss
Hepatitis B or C
____ ____ Renal Dialysis
Herpes
____ ____ Rheumatic Fever
High Blood Pressure
____ ____ Rheumatism
High Cholesterol
____ ____ Scarlet Fever
Hives or Rash
____ ____ Shingles
Hypoglycemia
____ ____ Sickle Cell Disease
Irregular Heartbeat
____ ____ Sinus Trouble
Kidney Problems
____ ____ Spina Bifida
Leukemia
____ ____ Stomach, Intestinal Disease
Liver Disease
____ ____ Stroke
Low Blood Pressure
____ ____ Swelling of Limbs
Lung Disease
____ ____ Thyroid Disease
Mitral Valve Prolapse ____ ____ Tonsillitis
Osteoporosis
____ ____ Tuberculosis
Pain in Jaw Joints
____ ____ Tumor or Growths
Parathyroid Disease
____ ____ Ulcers
Psychiatric Care
____ ____ Venereal Disease
Yellow Jaundice
Yes
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No
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____________________________________________________
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_______________________________________________________DATE_________________________