Medical History Form

Medical / Physician Information
Patient name*
First Middle Last
Preferred name
Birth Date*
Date Format: MM slash DD slash YYYY
Are you currently under a physician's care?
- No
- Yes
If yes, please explain
Physician name, practice, phone#
Date of last complete physical exam
Date Format: MM slash DD slash YYYY
History of serious head/neck injury?*
- No
- Yes
Have you ever been hospitalized or had a major operation?*
- No
- Yes
Do you have artificial heart valves or prostheses?*
- No
- Yes
Have you had history of endocarditis?*
- No
- Yes
Do you have a pacemaker?*
- No
- Yes
Do you have artificial joints (knee, hip, shoulder, elbow)?*
- No
- Yes
Have you taken antibiotics prior to dental appointments?*
- No
- Yes
Are you on a special diet?*
- No
- Yes
Do you consume non-diet soda?*
- No
- Yes
Do you use controlled substances?*
- No
- Yes
Do you consume alcohol?*
- No
- Yes
Do you use tobacco?*
- No
- Yes
If yes, how often and in what form
Women, please select all that apply
- Pregnant
- Trying to get pregnant
- Taking contraceptives
- Nursing

Medications, Vitamin, Supplements, Etc
Are you taking any medications, vitamins, supplements, pills or drugs?*
- No
- Yes

Medication

Medication Name	Dosage	Date Started	For what reason?

If more than five medications, please provide your own list or a list from your provider
Supplements/Vitamins
Have you ever taken Boniva, Fosamax, Actonel, or Reclast?*
- No
- Yes

Confirmation
Patient/guardian signature indicates the information provided in this form is complete and accurate
Please type your name*
First Last
Please select today's date*
Date Format: MM slash DD slash YYYY

Medical / Physician Information