Confidential Patient Information

First Name:
Middle Initial:
Last Name:

Medical History

Does the patient have any allergies or drug reactions to:
Select here if all answers BELOW are NO
Penicillin or Other Antibiotics
Sulfa Drugs
Aspirin, Ibuprofen, Tylenol
Local Anesthetics
Metal Allergy
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Select here if all answers BELOW are NO
Heart Murmur
Damaged or Artificial Heart Valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Liver Disease/Jaundice/Hepatitis
Kidney Disease
Heart Attack/Stroke
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia/Blood disorder
Tonsils/Adenoids Removed
Arthritis/Joint problems
Large Tonsils
Sinus Trouble
Bed Wetting
Substance Abuse Problem (Past or Present)
Bone Fractures/Trauma to Face/Jaw
Prosthetic Joints
Chronic Fatigue
Growth Problems
Tuberculosis or Lung Disease
Family History of Cancer
Received Radiation Treatment
Thyroid/Endocrine Problems
Stomach Ulcer or Hyperacidity
Hormone Therapy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures/Epilepsy/Neurological Disease
Treated for Emotional Problems
Respiratory Problems/Emphysema
Persistent Swollen Neck Glands
Sexually Transmitted Disease
Low Blood Pressure
Persistent Cough
Heart Condition
Autoimmune Disorder
Are you pregnant?
Do You Take Bisphosphonates (Fosamax, Boniva)
Has there been any change in the patient's general health within the last year?
If any of the above medical questions were answered 'Yes' , please explain: