Medical History

Patient Name

First Middle Last

Birth Date

Although dental personnel primarily treat the area in & around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication 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 had a major operation?

Yes
No

Have you ever had a serious head or neck injury?

Yes
No

Are you taking any medications, pills, or drugs?

Yes
No

Have you ever taken Fosamax, Boniva, Actonel, Xgeva or any medications containing Bisphosphonates?

Yes
No

Do you take, or have you taken, Phen-Fen or Redux?

Yes
No

Do you ever smoke or use tobacco?

Yes
No

Do you drink alcohol?

Yes
No

Are you on a special diet?

Yes
No

Do you use controlled substances?

Yes
No

Gender

Male
Female

Are you...

Pregnant
Trying to get pregnant
Nursing
Taking oral contraceptives

Do you have, or have you had, any of the following?

Do you have any serious previous or present medical or dental problems that: 1) are not listed above or, 2) you think the Dr. should know about?

Yes
No

Please tell us about any other medical or dental problems

Is there anything you wish to speak about in private with the doctor?

Yes
No

Doctor's Comments

I am the patient or parent/legal guardian authorized to provide the information requested. To the best of my knowledge, the questions on this form have been accurately and completely 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 that may occur in my medical status. I understand that payment for professional services are my sole responsibility and are due as services are rendered. Non-payment for services may result in additional collection fees. We do not render services on the basis that insurance companies will pay our fees, but we will be happy to assist you in filing claims for your insurance reimbursement. I authorize Dr. Christensen to diagnose and provide dental treatment for myself (or patient) including any necessary x-rays or photographs.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN

Date

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