Although dental personnel pnmarily 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, c |
Are you under a physician's care now? |
Yes No |
If Yes |
Have you ever been hospitalized or had a major operation? |
Yes No |
If Yes |
Have you ever had a serious head or neck injury? |
Yes No |
If Yes |
Are you taking any medications, pills,or drugs? |
Yes No |
If Yes |
Do you take, or have you taken, Phen-Fen or Redux? |
Yes No |
If Yes |
Have you ever taken fosamax, Boniva, Actonel or any other medications containing bisphosphonates? |
Yes No |
If Yes |
Are you on a special diet? |
Yes No |
If Yes |
Do you use tobacco? |
Yes No |
If Yes |
Do you use controlled substances? |
Yes No |
If Yes |
Women: Are you ... |
Pregnant/Trying to get pregnant? |
Nursing? |
Taking oral contraceptives |
Are you allergic to any of the following? |
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Other? |
Yes No |
If Yes |
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Do you have, or have you had, any of the following? |
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Have you ever had any serious illness not listed above? |
Yes No |
If Yes |
Comments:
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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 patient's) health. It is my responsibility to inform the dental office of any changes in medical status. |
Signature of Patient, Parent or Guardian: |
DATE |
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