Medical History Although dental personnel primarily treat the area 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 have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Name: Phone: Date of last medical exam: What was the exam for? Current Physician: Y N Women Y N Have you ever been hospitalized or had a major operation? Are you pregnant or trying to get pregnant? Are you under the care of a physician? Are you taking contraceptives? Have you ever had a serious head or neck injury? Are you nursing? Are you taking any medications or supplements? If yes please list, the dose and how often: Are you allergic to any of the following? (use back of paper if needed) Aspirin Penicillin Local Anesthetics Do you take or have you taken Phen-Fen or Redux? Acrylic Have you ever taken Fosamax, Boniva, Actonel or any Codeine other medications containing bisphosphonates? Metal Are you on a special diet? Latex Do you use Tobacco? Sulfa Drugs Do you use controlled substances? Other CHECK ALL THAT APPLY: FAMILY HISTORY UNKNOWN? YES NO

HAVE HAD FAMILY HAVE HAD FAMILY HAVE HAD FAMILY HISTORY HISTORY Acid Reflux HISTORYEpilepsy\Seizures Mitral Value Prolapse AIDS\HIV Positive Excessive Bleeding Osteoporosis Alzheimer’s Disease Excessive Thirst Pain in Jaw Joints Anaphylaxis Fainting Spells\Dizziness Parathyroid Disease Anemia Frequent Cough Psychiatric Care Angina Frequent Diarrhea Radiation Treatments Arthritis\Gout Frequent Headaches When? Artificial Heart Valve Genital Herpes Recent Weight Loss Artificial Joint: Glaucoma Renal Dialysis What Joint? Hay Fever Rheumatic Fever When? Heart Attack\Failure Rheumatism Asthma Heart Murmur Scarlet Fever Blood Disease Heart Pace Maker Shingles Blood Transfusion Heart Trouble\Disease Sickle Cell Disease Breathing Problem Hemophilia Sinus Trouble Bruise Easily Hepatitis A Sleep Apnea Cancer Hepatitis B or C Did you wear a c-pap? Y N Type? Herpes Spina Bifida Chemotherapy High Blood Pressure Stomach\Intestinal Disease When? High Cholesterol Stroke Chest Pains Hives or Rash Swelling of Limbs Cold Sores\Fever Blisters Hypoglycemia Thyroid Disease Congenital Heart Disorder Inflammatory disease Tonsillitis Convulsions Type? Tuberculosis Cortisone Medicine Irregular Heartbeat Tumors or Growths Diabetes Kidney Problems Ulcers Drug Addiction Leukemia Venereal Disease Dry Mouth Liver Disease Yellow Jaundice Easily Winded Low Blood Pressure Emphysema Lung Disease

HAVE EVER HAD ANY SERIOUS ILLNESS NOT LISTED ABOVE? YES NO If yes, please explain:

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: