First Name*

Last Name*

Birthdate

Email Address*

Phone Number*

Are you currently being treated by a physician for a specific condition?

Yes
No

If so, please tell us about your treatment

Have you recently been hospitalized or had a major operation?

Yes
No

If so, please tell us about the hospitalization

Have you ever had a serious head or neck injury?

Yes
No

If so, please tell us about the head/neck injury

Are you taking any medications, pills, or drugs?

Yes
No

Please list all medications and dosage

Are you on a special diet?

Yes
No

Please tell us about your diet

Do you use tobacco?

Yes
No

Please tell us how often and what type of tobacco consumption

Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.

Have you ever been advised that you require antibiotics prior to a dental appointment?

Yes
No

Please tell us about the antibiotics

Do you take, or have you taken, PhenFen or Redux?

Yes
No

If so, please tell us about your PhenFen/Redux usage

Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes
No

If so, please tell us about your bisphosphonate usage

Have you recently used controlled substances?

Yes
No

If so, please tell us which controlled substances and amount/frequency

Have you recently consumed alcohol?

Yes
No

Please tell how much alcohol and how recently

Women (Please check all that apply)

Pregnant
Trying to get pregnant
Currently nursing
Taking oral contraceptives
None of the above

Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic)*

Other

Do you have, or have you ever had any of the following medical conditions? (Please select all that apply)*

Do you have any condition or problem, not listed, which we should know about? Please explain

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*

Pediatric Dental

Orthodontic

Medical History