Step 2: Medical History

First Name *

Last Name *

Do you have, or have you had, any of the following? (Select All That Apply)

Have you ever had any serious illness not listed above?

No

Yes

Are you under a physician's care now?

No

Yes

Have you ever been hospitalized or had a major operation?

No

Yes

Have you ever had a serious head or neck injury?

No

Yes

Are you taking any medications, pills, or drugs?

No

Yes

Do you take, or have you taken, Phen-Fen or Redux?

No

Yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

No

Yes

Are you on a special diet?

No

Yes

Do you use tobacco?

No

Yes

Do you use controlled substances?

No

Yes

For Women: Are you

Pregnant/Trying to get pregnant?

Nursing/Breast Feeding?

Taking oral contraceptives?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient`s) health. It is my responsibility to inform the dental office of any changes in medical status.

Patient or Guardian's Signature

Clear

Relationship To The Patient

Your Name (If you are not the patient)