Are you under a physician’s care now?

YesNo

          If yes, please explain:

Have you ever been hospitalized or had a major operation?

YesNo

          If yes, please explain:

Have you ever had a serious head or neck injury?

YesNo

          If yes, please explain:

Are you taking any medications, pills, or drugs?

YesNo

          If yes, please explain:

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

YesNo

          If yes, please explain:

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

YesNo

          If yes, please explain:

Are you on a special diet?

YesNo

          If yes, please explain:

Do you use tobacco?

YesNo

          If yes, please explain:

Women: Are you Pregnant/Trying to get pregnant?

YesNo

king oral contraceptives?

YesNo

Nursing?

YesNo

Are you allergic or had a reaction to any of the following?

Dental AnestheticsPenicillinCodeineSulfa DrugsMetalAspirinLatex

Other :

If yes, please explain:

Do you use controlled substances?

YesNo

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

Have you ever had any serious illness not listed above?

YesNo

          If yes, please explain:

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 health.
It is my responsibility to inform the dental office of any changes in medical status.

Print patient name _______________________________________      Signature of patient or Guardian _______________________        Date ____________________________

Doctor Signature _________________________________________________________________________              Date ________________________________________