Patient Medical History Form

Patient Emergency Information
Emergency Contact #1
Emergency Contact #2
1) Are you under a physician's care now? *
2) Have you ever been hospitalized or had a major operation? *
3) Have you ever had a serious head or neck injury? *
4) Are you taking any medications, pills, drugs or controlled substances? *
5) Do you take, or have you ever taken, Phen-Fen or Redux? *
6) Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? *
Are you on a special diet? *
7) Do you use tobacco? *
Do you use controlled substances? *
8) Have you ever been told that you have gingivitis, or bleeding gums? *

13) Women: Are you *
 YesNoNot Applicable
Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Nursing?
14) Are you allergic to any of the following? *
 
15) Do you have, or have you had, any of the following? *
16) Have you ever had any serious illness not listed above? *
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 *
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