Patient Name:*
Birth Date:*
Although dental personnel primarily treat the area in and around your mouth, you mouth is a part of your entire body. Health problems that you may have, or medication
Are you under a physician's care now?
YesNo
Have you ever been hospitalized or has a major operation?
Have you ever had a seriod head or neck injury?
Are you taking any medication, pills, or drugs?
Do you take, or have you taken Phen-Fen or Redux?
Have you ever take Fosamax, Boniva, Actonel or any other medications containing bisphosphates?
Are you on a special diet?
Do you use tabacco?
Women: Are you... Pregnant/Trying to get pregnantNursingTaking oral contraceptives
Are you allergic to any of the following? AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal Anesthetics
Other?
Do you use controlled substances?
Do you have, or have had any of the following?
Have you have any serious illness not listed?
Comments?
