Medical History

Patient Name*

First Last

Date of Birth*

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

If yes, please list any medications, pills or drugs.

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

Yes
No

Are you on a special diet?*

Do you use tobacco?*

Yes
No

Do you use controlled substance?*

Yes
No

Women: Are you pregnant/trying to get pregnant?

Yes
No

Women: Are you taking oral contraceptives?

Yes
No

Women: Are you nursing?

Yes
No

If you have, or have had, any of the following please check:

Comments

If you have had any serious illnesses not listed above or put yes for any questions, please explain here.

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.*

Yes

Name

First Last

Date

SECURITY QUESTION: Please answer the following 2+2 =*

Email

This field is for validation purposes and should be left unchanged.

Monday	7:00AM - 5:00PM
Tuesday	7:00AM - 5:00PM
Wednesday	7:00AM - 5:00PM
Thursday	7:00AM - 5:00PM
Friday	7:00AM - 1:00PM
Saturday	CLOSED
Sunday	CLOSED

Patient Medical History

Business Hours

Office Info