Medical History Form

To complete this Medical History Form, simply fill out the fields with the requested information. While most of the fields are optional, certain fields marked by asterisks (*) must be completed. Please do not use your browser's Back or Forward buttons. Use of these buttons may “undo”/”redo” recent actions. Once you have completed this document, simply click the submit button to proceed.

Name

First

Middle

Last

Do you have, or have you had, any of the following?

Have you ever had any serious illness not listed above?

No
Yes

If yes, please list any serious illness not listed above.

Are you under a physician's care now?

No
Yes

If yes, please provide physician's name.

Have you ever been hospitalized/had a major surgery?

No
Yes

If yes, please explain.

Have you ever had a serious head or neck injury?

No
Yes

If yes, please explain.

Do you have any Medical Concerns?

No
Yes

If yes, please explain.

Do you take, or have you taken, Phen-Fen or Redux?

No
Yes

If yes, please explain

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

No
Yes

If yes, please explain.

Are you on a special diet?

No
Yes

Do you use tobacco products?

No
Yes

Are you allergic to any of the following?

Do you take any medications or Supplements?

No
Yes

If yes, please explain.

Women: Are you...

Pregnant/Possibly pregnant?
Taking oral contraceptives?
Nursing?

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

Please draw your signature in the box. Use the X to clear your signature.

Relationship to the Patient

Name if not the Patient

Contact Number if not the Patient

Please carefully review your information before submitting this document.

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