Medical History

After you click the Submit button below, you will be taken to the 
Patient Registration Form which must also be completed.

Although dental personnel primarily treat the area in and around the 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.

PATIENT FULL NAME:
PATIENT E-MAIL ADDRESS:

Are you under a physicians care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take or have you taken, Phen-Fen or Redux?
Do you use tobacco?
Are you on a special diet?   
Do you use controlled substances?
Women: Are you

Are you allergic to any of the following?
Aspirin, Penicillin, Codeine, Acrylic, Metal, Latex, 
Local Anesthetics, Other:

Do you have, or have you had, any of the following:

AIDS/HIV Positive Chest Pains Frequent Headaches Irregular Heartbeat Scarlet Fever
Alzheimer's Disease Cold Sores/Fever Blisters Genital Herpes Kidney Problems Shingles
Anaphylaxis Congenital Heart Disorder Glaucoma Leukemia Sickle Cell Disease
Anemia Convulsions Hay Fever Liver Disease Sinus Trouble
Angina Cortisone Medicine Heart Attack/Failure Low Blood Sugar Spina Bifida
Arthritis/Gout Diabetes Heart Murmur* Lung Disease Stomach/Intestinal Disease
Artificial Heart Valve* Drug Addiction Heart Pace Maker* Mitral Valve Prolaspse* Stroke
Artificial Joint* Easily Winded Heart Trouble/Disease Pain in Jaw Joints Swelling of Limbs
Asthma Emphysema Hemophilia Parathyroid Disease Thyroid Disease
Blood Disease Epilepsy or Seizures Hepatitis A Psychiatric Care Tonsillitis
Blood Transfusion Excessive Bleeding Hepatitis B or C Radiation Treatments Tuberculosis
Breathing Problem Excessive Thirst Herpes Recent Weight Loss Tumors or Growths
Bruise Easily Fainting Spells/Dizziness High Blood Pressure Rental Dialysis Ulcers
Cancer Frequent Cough Hives or Rash Rheumatic Fever* Venereal Disease
Chemotherapy Frequent Diarrhea Hypoglycemia Rheumatism Yellow Jaundice

Have you ever had any serious illness not listed above?
If so, please give us your specific comments:

NOTE * = Conditions may require medication.

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 me (or patient's) health.  It is my responsibility to inform the dental office of any changes in medical status.

Electronically signed by Patient, Parent, or Guardian on this date:
Signature:


 

 

Copyright 2003 Laguna Hills Dental. All Rights Reserved