Medical HistoryΔ Leigh Bailey Werner D.D.S., P.C. - Evansdale Family Dentistry Medical History FormPatient NameFirst NameLast NameAlthough 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.PreviousNextAre you currently under a physician's care? Yes NoIf yes, please explain:Have you ever been hospitalized or had a major operation? Yes NoIf yes, please explain:Have you ever had a serious head or neck injury? Yes NoIf yes, please explain:Do you take, or have you taken, Phen-Fen or Redux? Yes NoHave you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes NoDo you take controlled substances? Yes NoIf yes, please provide more informationWomen Only: Are you Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?Please mark any of the substances below that you are allergic to: Aspirin Penicillin Acrylic Metal Latex Sulfa Drugs Local Anesthetics None of the AboveDo you have, or have you had, any of the following medical conditions. illnesses or treatments?Please check the box next to the conditions or illnesses listed that apply to you. AIDS/HIV Positive Alzheimer's Anaphilaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusio Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Diziness Frequent Cough Frequent Diarrhea Freequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weightloss Renal Dialysis Rheumatic Fever Rheumatism Scarlett Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow JaundiceHave you ever had any serious illness not listed above? Yes NoIf yes, please elaborate: Additional Comments:To the best of my knowledge, the questions above are accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.Type your name as signatureDate Previous Submit Download Medical History Form: Download
