Neligh Family Dental - Online Patient Medical History Form

Name*

First NameLast Name

Date*

Date

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? If yes, please explain.*

Are you taking any medications, pills or drugs? If yes, please explain.*

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

YesNo

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

YesNo

Are you on a special diet?*

YesNo

Do you use tobacco?*

YesNo

Do you use controlled substances?*

YesNo

Pregnant/Trying To Get Pregnant?*

YesNo

Taking Oral Contraceptives?*

YesNo

Nursing*

YesNo

Are you allergic to any of the following:*

What medications are you taking, including nonprescription or herbal medications?*

If other, please explain.

AIDS/HIV Positive*

YesNo

Cortisone Medicine*

YesNo

Hemophilia*

YesNo

Radiation Treatments*

YesNo

Alzheimer's Disease*

YesNo

Diabetes*

YesNo

Hepatitis A*

YesNo

Recent Weight Loss*

YesNo

Anaphylaxis*

YesNo

Drug Addiction*

YesNo

Hepatitis B or C*

YesNo

Renal Dialysis*

YesNo

Anemia*

YesNo

Easily Winded*

YesNo

Herpes*

YesNo

Rheumatic Fever*

YesNo

Angina*

YesNo

Emphysema*

YesNo

High Blood Pressure*

YesNo

Rheumatism*

YesNo

Arthritis/Gout*

YesNo

Epilepsy or Seizures*

YesNo

High Cholesterol*

YesNo

Scarlet Fever*

YesNo

Artificial Heart Valve*

YesNo

Excessive Bleeding*

YesNo

Hives or Rash*

YesNo

Shingles*

YesNo

Artificial Joint*

YesNo

Excessive Thirst*

YesNo

Hypoglycemia*

YesNo

Sickle Cell Disease*

YesNo

Asthma*

YesNo

Fainting Spells/Dizziness*

YesNo

Irregular Heartbeat*

YesNo

Sinus Trouble*

YesNo

Blood Disease*

YesNo

Frequent Cough*

YesNo

Kidney Problems*

YesNo

Spina Bifida*

YesNo

Breathing Problem*

YesNo

Frequent Diarrhea*

YesNo

Leukemia*

YesNo

Stomach/Intest. Disease*

YesNo

Blood Transfusion*

YesNo

Frequent Headaches*

YesNo

Liver Disease*

YesNo

Stroke*

YesNo

Bruise Easily*

YesNo

Genital Herpes*

YesNo

Low Blood Pressure*

YesNo

Swelling of Limbs*

YesNo

Cancer*

YesNo

Glaucoma*

YesNo

Lung Disease*

YesNo

Thyroid Disease*

YesNo

Chemotherapy*

YesNo

Hay Fever*

YesNo

Mitral Valve Prolapse*

YesNo

Tonsillitis*

YesNo

Chest Pains*

YesNo

Heart Attack/Failure*

YesNo

Osteoporosis*

YesNo

Tuberculosis*

YesNo

Cold Sores/Fever Blisters*

YesNo

Heart Murmur*

YesNo

Pain In Jaw Joints*

YesNo

Tumors or Growths*

YesNo

Congenital Heart Disease*

YesNo

Heart Pacemaker*

YesNo

Parathyroid Disease*

YesNo

Ulcers*

YesNo

Convulsions*

YesNo

Heart Trouble/Disease*

YesNo

Psychiatric Care*

YesNo

Venereal Disease*

YesNo

Yellow Jaundice*

YesNo

Have you ever had any serious illness not listed above? If yes, please explain.

Date*

Date

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 my medical status.

Neligh Family Dental - Online Patient Medical History Form

Women, are you:

You will sign this form at your office visit.