Medical History Form

New patients can save time when they visit our office for the first time by completing their required paperwork in advance.

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? Yes   No
If yes:
Have you ever been hospitalized or had a major operation? Yes   No
If yes:
Have you ever had a serious head or neck injury? Yes   No
If yes:
Are you taking any medications, pills, or drugs? Yes   No
If yes:
Do you take, or have you taken, Phen-Fen or Redux? Yes   No
If yes:
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates? Yes   No
If yes:
Are you on a special diet? Yes   No  
Do you use tobacco? Yes   No  
Do you use controlled substances? Yes   No
If yes:

Women, are you:
Pregnant/trying to get pregnant   Nursing   Taking oral contraceptives

Are you allergic to any of the following?

Do you now have, or have ever had, any of the following:

Have you ever had any other serious illness not checked above? Yes   No
If yes:

  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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Member - American Dental Association Member - Tennessee Dental Association Member - Doctors for Conscious Sedation Member - First Districts Dental Member - Academy for General Dentistry Remote Area Medical Board Lead Dentist American Academy of Facial Esthetics
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