Medical History
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 f or answering the following questions
Printed Name (Patient) *
Email *
Date of birth (Patient) *
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YYYY
Today's Date *
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DD
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Physician name and telephone number
Have you ever been hospitalized or had a major operation?
Clear selection
If yes
Have you ever had a serious head or neck injury?
Clear selection
If yes
Are you taking any medications, vitamins, or herbs?
Clear selection
If yes
Do you need pre-med before dental visits?
Clear selection
If yes
Have you ever taken Fosamax,Boniva, Actonel or any other medications containing bisphosphonates?
Clear selection
If yes
Are you on a blood thinner?
Clear selection
Do you use tobacco or vape? *
Do you use medical or recreational marijuana?
Clear selection
If yes
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