Medical History Form Patient Name First Last Physician's Name PhoneHave you had any medical care within the past two years? Yes No Please DescribeHave you taken any medication or drugs during the past two years? Yes No Please List Name & DosageAre you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin? Yes No Please List Name & DosageHave you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other bisphosphonates? Yes No Please List Name & DosageAre you aware of having an allergic (or adverse) reaction to any substance or medication? Yes No Please SpecifyHave you been a patient in the hospital during the past five years? Yes No Indicate which of the following you have had, or have at present. Check the box if it applies to you. Heart (Surgery, Disease, Attack) Chest Pain Congenital Heart Disease Heart Murmur High/Low Blood Pressure Mitral Valve Prolapse Artifical Heart Valve/Pacemaker Rheumatic Fever Arthritis/Rheumatism Cortisone Medicine Swollen Ankles Stroke Diet (Special/Restricted) Artificial Joints (hip, knee, etc.) Kidney Trouble Ulcers Diabetes Thyroid Problems Glaucoma Contact Lenses Emphysema Chronic Cough Tuberculosis Asthma Hay Fever/Allergy/Hives Latex Sensitivity Sinus Trouble Radiation Therapy Chemotherapy Tumors Hepatitis A Hepatitis B Hepatitis C Venereal Disease A.I.D.S./H.I.V. Positive Cold Sores/Fever Blisters Blood Transfusion Hemophilia Sickle Cell Disease Bruise Easily Liver Disease/Yellow Jaundice Neurological Disorders Epilepsy or Seizures Fainting or Dizzy Spells Nervous/Anxious Psychiatric/Psychological Care Cancer Have you lost or gained more than 10 pounds in the last year? Yes No Do you have or have you had any disease, condition, or problem not listed? Yes No Please ListWomen:Are you pregnant or think you could be pregnant? Yes No Months?Please enter a number from 1 to 12.Nursing? Yes No Do you use birth control prescriptions? Yes No I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any charge in my health or medication. Patient Signature Date MM slash DD slash YYYY