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PATIENT NAME: _____________________________________________________ DATE OF BIRTH: _______________________
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?
Yes No ____________________________________________
Have you ever been hospitalized/or major surgery? Yes No ____________________________________________
Have you ever had a serious head or neck injury? Yes No____________________________________________
Are you taking any medications, pills, or drugs? Yes No **** SEE BACK OF SHEET TO LIST ****
Do you take or have you taken Phen-Fen or Redux? Yes No
Are you on a special diet? Yes No
Do you use tobacco? Yes No
Do you use controlled substances? Yes No Women:
Are you: Pregnant Trying to get pregnant Nursing Taking oral contraceptives
Are you allergic to any of the following:
Aspirin Penicillin Amoxicillin Erythromycin Codeine Acrylic Metal Latex Local Anesthetics
Sulfa Drugs Food Allergies Barbiturates, Sedatives, etc. Other ____________________________________________
Mitral Valve Prolapse
Have you ever had any serious illness not listed above? Yes No N/A _______________________________________________________
Yes No I AM INTERESTED IN ORTHODONTICS (BRACES) TO STRAIGHTEN MY TEETH. Yes No I AM INTERESTED IN COSMETIC DENTISTRY. Yes No I AM CONCERNED ABOUT MY BREATH. Yes No I AM INTERESTED IN BLEACHING (WHITENING) MY TEATH.
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 the patient’s) health. It is my responsibility to inform the dental office of any changes in medical status in the future prior to treatment. I understand that I will be asked to update this page on a regular basis.
_____________________________________________________ __________________________________________ Signature of Patient, Parent, or Guardian Date
PLEASE CIRCLE ANY OF THE FOLLOWING THAT YOU ARE TAKING:
ANXIETY / DEPRESSION MEDICATION
PAXIL (PAROXETINE) VOLTAREN (DICLOFENAC)
PLEASE LIST ANY MEDICATIONS
YOU ARE TAKING AND NOT LISTED ABOVE.
NAME OF MEDICATION
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