Health…

                                                          Health History

Patient Name:

Indicate which of the following you have had or have at the present? Please check those that apply:

                           Yes       No                                 Yes      No                                  Yes       No
AIDS                                         Emphysema                                    Nervous Disorders            
Anemia                                       Epilepsy                                     Pregnancy                    
Allergy to Latex                             Excessive Bleeding                           Due Date ______________
Angina Pectoris                              Fever blisters                               Pacemaker                    
Allergy to metal                             Fainting                                     Penicillin Allergy           
(jewelry, etc.)                              Glaucoma                                     Radiation treatment          
Alcohol Abuse                                Heart Failure                                Respiratory problems         
Arthritis/Rheumatism                         Head Injuries                                Rheumatic fever              
Arteriosclerosis                             Hives                                        Sinus problems               
Artificial Joints                            Hay Fever                                    Stomach problems             
Artificial Rods or Pins                      Heart Disease or attack                      Stroke                       
Asthma                                       Heart Murmur                                 Seizures                     
Blood Disease                                H.I.V. Positive                              Tuberculosis                 
Blood transfusion                            Hepatitis A (infectious)                     Tumors                       
Cancer                                       Hepatitis B (Serum)                          Ulcers                       
Cold sores                                   Hepatitis C                                  Venereal disease             
Codeine Allergy                              High blood pressure                          Osteoporosis medications
Cortisone medication                         Jaundice                                     Fosomax or                   
Convulsions                                  Kidney transplant                            Bonine                       
Diabetes                                     Liver Disease                                Others Not Listed            
or Dialysis                                  Lupus                                        ______________________________
Drug addiction                               Leukemia                                     ______________________________
Drug Abuse                                   Lung Disorders                      
Dizziness                                    Mental Disorders                    
Embolism                                     Mitral Valve Prolapse               


When was your last Dental Exam? __________________________________________________________________________
When was your last full mouth x-rays? ______________________________________________________________________
Have you had to take antibiotics before any dental treatment?  Yes  No            If so why? ____________________________
Have you ever had any complications following dental treatment?  Yes  No
  If yes, please explain: __________________________________________________________________________________
Are you sensitive or allergic to any medication or anesthetics?    Yes  No If yes, please list: ______________________
Have you been admitted to a hospital or needed emergency care during the past two years?  Yes  No
  If yes, please explain: __________________________________________________________________________________
Are you now under the care of a physician?  Yes  No If yes, please explain: _________________________________
Name of Physician: _________________________________________ Phone: _______________________________________
Do you have any health problems that need further clarification?  Yes  No
 If yes, please explain: ___________________________________________________________________________________
List all medications you are currently taking: __________________________________________________________________
_______________________________________________________________________________________________________
Have you ever taken appetite suppressants - fen-phen (Fenluramine & Phentermine) or dexenflurameine?         Yes      No
Have you been under the care of a medical doctor during the last two years or since taking any of the appetite suppressants named
above?  Yes  No If yes, Physicians Name: ________________________ Phone#: _______________________________

For Women Only: Are you taking birth control?  Yes  No               If yes, patient has to seek other methods of contraceptives while
Taking antibiotics, or risk pregnancy.
1. The undersigned hereby authorizes doctor to order x-rays, study models, photographs, or any other diagnostic aids deemed
   appropriate by doctor to make a thorough diagnosis of the patient's dental needs.

2. I also authorize doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate
    medication and therapy indicated for such treatment in connection with (name of patient) ________________________.
    I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that doctor choose
   and employ such assistance as deemed fit to provide all recommended treatment.

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. To
the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever
Have any change in my health, I will inform the doctors at the next appointment without fail.

______________________________________________________                              Date: ___________________________
Signature of patient, parent or guardian




                                                 Medical History Update


I have read my MEDICAL HISTORY dated _______________ and confirm that adequately states past and present
Conditions.
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