Medical History Form Name* First Last Birth Date* MM slash DD slash YYYY Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.Are you under a physician's care now?* Yes No If yes Have you ever been hospitalized or had a major operation?* Yes No If yes Have you ever had a serious head or neck injury?* Yes No If yes Are you taking any medications, pills, or drugs?* Yes No If yes Do you take, or have you taken, Phen-Fen or Redux?* Yes No If yes Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?* Yes No If yes Are you on a special diet?* Yes No If yes Do you use tobacco or vape?* Yes No If yes Do you use controlled substances?* Yes No If yes Have You received your COVID-19 vaccination?* Yes No 1st Dose Date MM slash DD slash YYYY 2nd Dose Date MM slash DD slash YYYY Women: Are you... Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives? Are you allergic to any of the following? Aspirin Metal Penicillin Latex Codeine Sulfa Drugs Acrylic Local Anesthetics Other If yes Do you have, or have you had, any of the following?Do you have, or have you had, any of the following? 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 Convulsions Yellow Jaundice Cortisone Medicine Diabetes Dementia 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 Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Hearing Loss Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Have you ever had any serious illness not listed above?* Yes No If yes CommentsSignature*Reset to re-sign.*The patient(s)/parties acknowledge and agree that the patient’s forms may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed or emailed versions of an original signature or electronically scanned and transmitted versions (e.g., via pdf) of an original signature. 81744 If would prefer to download this form, please click HERE. Next Form: HIPAA Form
