Medical History

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

Medical History Form

Name(Required)

First Last

Birth Date(Required)

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

If yes, please explain:

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

Yes

If yes, please explain:

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

Yes

If yes, please explain:

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

Yes

If yes, please explain:

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

Yes

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

Yes

Are you on a special diet?(Required)

Yes

Do you use tobacco?(Required)

Yes

Do you use controlled substances?(Required)

Yes

Women: Are you

Pregnant/Trying to get pregnant?

Yes

Taking oral contraceptives?

Yes

Nursing?

Yes

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

Have you ever had any serious illeness not listed above?

Yes

What is it?

Comment:

Name OF PATIENT, PARENT, or GUARDIAN(Required)

Date(Required)

Signature(Required)

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

Medical History Form

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CONTACT DETAILS

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Dental Vision

Dental Treatments

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