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Medical History Form

Medical History Form

"*" indicates required fields

Step 1 of 4

Name*
MM slash DD slash YYYY

Although dental personnel primarily treat the area in and 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.

Are you under a physician’s care now?*
Have you ever been hospitalized or had a major operation?*
Have you ever had a serious head or neck injury?*
Are you taking any medications, pills, or drugs?*
Do you take, or have you taken, Phen-Fen or Redux?*
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*
Are you on a special diet?*
Do you use tobacco?*
Do you use controlled substances?*