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Medical History
Patient's Full Name *
Your answer
Patient's Birth 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.
For the following questions if your answer is yes, please choose 'other' and explain
Are you under a physician's care now? *
Have you ever been hospitalized or had a major operation? *
Have you ever had a serious head or neck injury? *
Are you taking any medications, pills, or drugs? *
Do you take, or have you taken, Phen-Fen or Redux? *
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing biophosphonates? *
Are you on a special diet? *
Do you use tobacco? *
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