Medical History - Legacy Dental

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(561) 600-9293

6651 West Woolbright Road, Suite 116

Boynton Beach, Florida 33437

Opening Hours

Monday – Thursday
9:00 AM – 5:00 PM
Friday
10:00 AM – 2:00 PM

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Medical History

Understanding your medical history helps us provide you with the best dental care possible

Medical Historyramzi@thewizard.marketing2024-04-02T03:50:46+00:00

Medical History Form

Name(Required)

First Last

Birth Date(Required)

MM slash DD slash YYYY

Email(Required)

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?(Required)

Yes

No

If yes, please explain:

Have you ever been hospitalized or had a major operation?(Required)

Yes

No

If yes, please explain:

Have you ever had a serious head or neck injury?(Required)

Yes

No

If yes, please explain:

Are you taking any medications, pills, or drugs?(Required)

Yes

No

If yes, please explain:

Do you take, or have you taken, Phen-Fen or Redux?(Required)

Yes

No

Have you either taken Fosamax, Boniva, Actonel or any other medications containing Bosphosphonates?(Required)

Yes

No

Are you on a special diet?(Required)

Yes

No

Do you use tobacco?(Required)

Yes

No

Do you use controlled substances?(Required)

Yes

No

Women: Are you

Pregnant/Trying to get pregnant?

Yes

No

Taking oral contraceptives?

Yes

No

Nursing?

Yes

No

Are you allergic to any of the following?

Are you allergic to any of the following

Aspirin

Penicilin

Codeine

Local Anesthetics

Acrylic

Metal

Latex

Sulfa drugs

Other

Please explain:

Do you have, or have you had, any of the following?

Untitled

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial heart valve

Asthma

Artificial Joint

Blood Disease

Blood Transfusion

Breathing Problem

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores/ Fever Blisters

Congenital Heart Disorder

Convulsions

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emshysema

Epilepsy Or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells/Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glocauma

High Fever

Heart Attack/Failure

Heart Murmur

Heart Trouble/disease

Heart Pacemaker

Hemophilia

Untitled

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heart Beat

Kidney Problems

Leukenia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain in Jaw Joints

Parathyroid Disease

Psychiatric Care

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatism

Rheumatic Fever

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach/Intestinal Disease

Stroke

Swelling Of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumor or Growth

Ulcers

Venereal Disease

Yellow Jaundice

Have you ever had any serious illeness not listed above?

Yes

No

What is it?

Comment:

Consent(Required)

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patients) health. it is my responsibility to inform the dental office of any changes in medical status.

Name OF PATIENT, PARENT, or GUARDIAN(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Δ

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Legacy Dental Team gives you a reason to keep smiling and to feel confident about it!

CONTACT DETAILS

6651 West Woolbright Road, Suite 116 Boynton Beach, Florida 33437
(561) 600-9293
info@legacydentalteam.com

6651 West Woolbright Road, Suite 116 Boynton Beach, Florida 33437
(561) 600-9293
info@legacydentalteam.com
Monday – Thursday

9:00 AM – 5:00 PM
Friday
10:00 AM – 2:00 PM

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