Virginia Center for Advanced DentistryMedical History Form - Virginia Center for Advanced Dentistry

Name

First Last

Gender

Male
Female

Birth Date

Email

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Heath 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.

Are you under a physician's care now?

Yes
No

If yes, please explain

Have you ever been hospitalized or had a major operation?

Yes
No

If yes, please explain

Have you ever had a serious neck or head injury?

Yes
No

If yes, please explain

Are you taking and medications, pills, or drugs?

Yes
No

If yes, please explain

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

Yes
No

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

Yes
No

Are you on a special diet?

Yes
No

Do you use tobacco?

Yes
No

Do you use tobacco?

Yes
No

Do you use tobacco?

Yes
No

Do you use controlled substances?

Yes
No

Are you trying to get pregnant?

Yes
No

Taking oral contraceptives?

Yes
No

Nursing?

Yes
No

Are you alergic to any of the following?

Asprin
Penicillin
Codeine
Local Anasthetics
Arcrylic
Metal
Latex
Sulfa Drugs
Other

If yes, please explain

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

AIDS/HIV Positive

Yes
No

Alzheimer's Disease

Yes
No

Anaphylaxis

Yes
No

Anemia

Yes
No

Angina

Yes
No

Arthritis/Gout

Yes
No

Artifical Heart Valve

Yes
No

Artifical Joint

Yes
No

Asthma

Yes
No

Blood Diease

Yes
No

Blood Transfusion

Yes
No

Breathing Problem

Yes
No

Bruise Easily

Yes
No

Bruise Easily

Yes
No

Cancer

Yes
No

Chemotherapy

Yes
No

Chest Pains

Yes
No

Cold Sores/Fever Blisters

Yes
No

Congenital Heart Disorder

Yes
No

Convulsions

Yes
No

Cortisone Medicine

Yes
No

Diabetes

Yes
No

Drug Addiction

Yes
No

Eaisly Winded

Yes
No

Emphysema

Yes
No

Epilepsy or Seizures

Yes
No

Excessive Bleeding

Yes
No

Excessive Thirst

Yes
No

Fainting Spells/Dizziness

Yes
No

Frequent Cough

Yes
No

Frequent Diarrhea

Yes
No

Frequent Headaches

Yes
No

Genital Herpes

Yes
No

Glacoma

Yes
No

Hay Fever

Yes
No

Heart Attack/Failure

Yes
No

Heart Murmur

Yes
No

Heart Pacemaker

Yes
No

Heart Trouble/Disease

Yes
No

Hemophilia

Yes
No

Hepatitis A

Yes
No

Hepatitis B or C

Yes
No

Herpes

Yes
No

High Cholesteral

Yes
No

Hives or Rash

Yes
No

Hypoglycemia

Yes
No

Irregular Heartbeat

Yes
No

Kidney Problems

Yes
No

Leukemia

Yes
No

Liver Disease

Yes
No

Low Blood Pressure

Yes
No

Lung Disease

Yes
No

Mitral Vavle Prolapse

Yes
No

Osteoporosis

Yes
No

Pain in Jaw Joints

Yes
No

Parathyroid Disease

Yes
No

Psychiatric Care

Yes
No

Radiation Treatments

Yes
No

Recent Weight Loss

Yes
No

Renal Dialysis

Yes
No

Rheumatic Fever

Yes
No

Rheumatism

Yes
No

Scarlet Fever

Yes
No

Shingles

Yes
No

Sickle Cell Disease

Yes
No

Sinus Trouble

Yes
No

Spina Bifida

Yes
No

Stomach/Intestinal Disease

Yes
No

Stroke

Yes
No

Swelling of Limbs

Yes
No

Thyroid Diease

Yes
No

Tonsillitis

Yes
No

Tuberculosis

Yes
No

Tumors or Growths

Yes
No

Ulcers

Yes
No

Venereal Disease

Yes
No

Yellow Jaundice

Yes
No

Have you had any serious illness not listed above?

Yes
No

If yes, please list

Comments

By typing my name below and submitting this form with the best of my knowledge, the questions on the 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.

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