First Name *

Last Name

Phone *

Email *

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 answer if filling this form out on the day of your appointment

Please tell how much alcohol and how recently

If other, please list

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.

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Medical History

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