Medical History Record ** * 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 medication that you may be taking, could. Are you under a physician's care now?*YesNoHave you ever been hospitalized or had a major operation?*YesNoHave you ever had a serious head or neck injury?*YesNoAre you taking medications, pills, or drugs?*YesNoDo you take, or have you taken, Phen-Fen or Redux?*YesNoHave you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*YesNoAre you on a special diet?*YesNoDo you use tobacco?*YesNoDo you use controlled substances?*YesNoWomen: 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 Acryllic Local Anesthetics Other? If yesDo you have, or have you had, any of the following? AIDS/HIV Positive Cortisone Medicine Hemophilia Radiation Treatments Alzheimer's Disease Diabetes Hepatitis A Recent Weight Loss Anaphylaxis Drug Addiction Hepatitis B or C Renal Dialysis Anemia Easily Winded Herpes Rheumatic Fever Angina Emphysema High Blood Pressure Rheumatism Arthritis/Gout Epilepsy or Seizures High Cholesterol Scarlet Fever Artificial Heart Valve Excessive Bleeding Hives or Rash Shingles Artificial Joint Excessive Thirst Hypoglycemia Sickle Cell Disease Asthma Fainting Spells/Dizziness Irregular Heartbeat Sinus Trouble Blood Disease Frequent Cough Kidney Problems Spina Bifida Blood Transfusion Frequent Diarrhea Leukemia Stomach/Intestinal Disease Breathing Problems Frequent Headaches Liver Disease Stroke Bruise Easily Genital Herpes Low Blood Pressure Swelling of Limbs Cancer Glaucoma Lung Disease Thyroid Disease Chemotherapy Hay Fever Mitral Valve Prolapse Tonsillitis Chest Pains Heart Attack/Failure Osteoporosis Tuberculosis Cold Sores/Fever Blisters Heart Murmur Pain in Jaw Joints Tumors or Growths Congenital Heart Disorder Heart Pacemaker Parathyroid Disease Ulcers Convulsions Heart Trouble/Disease Psychiatric Care Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above?*YesNoIf yesComments:Signature of Patient, Parent or Guardian*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.* PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.