Patient Forms

Medical History

Please complete all sections as accurately as possible. This information is essential for your safety and proper dental care.

HIPAA Compliant · All information is encrypted and kept confidential

General Info

Conditions

Allergies

Dental History

Signature

Medical & General Health

Physician information and current health status

Physician Information

Physician Name

Office Phone

Date of Last Exam

Are you currently under a physician's care?

For what condition?

Have you been hospitalized in the past 5 years?

Reason for hospitalization

Are you currently taking any medications, pills, or drugs?

List all medications

Have you ever taken Phen-Fen or bisphosphonate drugs (e.g., Fosamax, Boniva, Actonel)?

Do you follow a special diet?

Do you use tobacco products?

Do you use controlled substances?

Women only

Pregnant / trying to become pregnant?

Taking oral contraceptives?

Currently nursing?

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