Although our Dental Team primarily treats areas in and around your mouth the health of your entire body can influence treatment you may receive. Certain health conditions or medication can have significant interactions with the dentistry you may receive. Please answer the following questions as accurately as possible, Thank You!
Are you under a physician’s care now?
If yes, please explain:
Have you ever been hospitalized or had a major operation?
If yes, please explain:
Have you ever had a serious head or neck injury?
If yes, please explain:
Have you ever taken, Phen-Fen, Redux, Fosamax?
Are you on a special diet?
If yes, please explain:
Do you use tobacco?
Do you use controlled substances?
If yes, please explain:
Please list any medications, pills, or drugs you are taking:
Women
Are you pregnant or trying to get pregnant?
Taking oral contraceptives?
Nursing?
Are you allergic to any of the following?
If yes, please explain:
Do you have, or have you had, any of the following?
Signature
I certify that the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or my patient’s) health I will not hold my Dentist or any members of his/her Dental Team responsible for errors or emissions that I have made in completion of this form. It is my responsibility to notify my Dentist of any changes in the above medical status.
Patient or Responsible Party Signature: X
Date:
Email:
ADAIDM/12-08