<p> ■ Medical History ■</p><p>Patient’s Name:______DOB______Today’s Date______Physician’s Name:______Physician’s Phone:______List ALL medications currently taking (including supplements):______Prosthetic Heart Valve, Joint Replacement (i.e. Hip, Knee, Ankle, etc)? ❑ Yes ❑ No Date:______Told that you need pre-medication prior to dental treatment: ❑ Yes ❑ No ______Blood Thinners: ❑ Baby Asprin ❑ Asprin ❑ Plavix ❑ Coumadin ❑ Predaxa ❑Other______Allergies: ❑ Latex ❑ Metals ❑ Penicillin Other______Bisphosphonate Use (Osteoporosis Meds): ❑ Boniva ❑ Actonel ❑ Zometa ❑ Other______Females: ❑ Birth Control Medication ❑ Pregnant: # Weeks______Are you Nursing? ❑ Y ❑ N</p><p>Y/N Conditions Y/N Conditions Y/N Conditions Y/N Conditions ❑ ❑ Anemia ❑ ❑ Diabetes ❑ ❑ Herpes ❑ ❑ HPV ❑ ❑ Abnormal Bleeding ❑ ❑ Difficulty Breathing ❑ ❑ HIV+ AIDS ❑ ❑ Kidney Problems ❑ ❑ Angina ❑ ❑ Drug Addiction ❑ ❑ Heart Attack ❑ ❑ Liver Disease ❑ ❑ Arthritis ❑ ❑ Emphysema ❑ ❑ Heart Disease/Surgery ❑ ❑ Pace Maker ❑ ❑ Asthma ❑ ❑ Fainting/Dizzy Spells ❑ ❑ Hemophilia ❑ ❑ Seizures ❑ ❑ Autoimmune ❑ ❑ Fever Blisters ❑ ❑ Hepatitis A, B or C ❑ ❑ Stroke ❑ ❑ Cancer/Radiation ❑ ❑ GI Disease or Reflux ❑ ❑ High Blood Pressure ❑ ❑ Thyroid Disease</p><p>Other Medical Condition not mentioned above:______Notes:______■ Dental History ■</p><p>Y/N Y/N Y/N Y/N ❑ ❑ Sensitive Teeth ❑ ❑ Jaw Pain (TMJ) ❑ ❑ Bleeding Gums ❑ ❑ Bad Breath ❑ ❑ Discolored Teeth ❑ ❑ Clenching/Grinding ❑ ❑ Periodontal Disease ❑ ❑ Tobacco Use ❑ ❑ Dry Mouth ❑ ❑ Cracked Teeth ❑ ❑ Tooth Trauma ❑ ❑ Crooked Teeth</p><p>Other Dental Conditions not mentioned above:______I understand the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. Signature: ______Date: ______</p><p>Dentist :______Date:______</p>