Medical History
Physician’s Name: Do you use alcohol? Yes No
Address/Clinic: Do you smoke or use tobacco in any other form? Yes No
Phone #: Date of last visit: Have you ever taken Fosamax or any other medication
Your current physical health is: Good Fair Poor for bone preservation? Yes No
Are you currently under the care of a physician? Yes No For Women: Are you taking birth control pills? Yes No
Please explain: Are you pregnant? Unsure Yes No
Week # Are you nursing? Yes No
Please check all conditions that you do have or have experienced in the past
Heart Problems / Surgery Congenital Heart Defects Diabetes ( I / II ) Epilepsy/Seizures Sexually Transmitted Disease
Low Blood Pressure Pacemaker Liver Problems Headaches High Blood Pressure
Asthma, Emphysema Hepatitis ( A, B, or C ) Anxiety Lupus Abnormal Bleeding / Disorder
Persistent Cough Kidney Problems Psychiatric Problems Arthritis Anemia
Tuberculosis Stroke Artificial Bones/Joints Drug Abuse Endocarditis
Ulcers Depression Cancer Glaucoma Artificial Heart Valve
Colitis or Irritable Bowel Dizzy or Fainting Spells HIV/AIDS Thyroid Problems
Blood Transfusion Hay Fever Herpes/Fever Blister Radiation/Chemotherapy
Rheumatic/Scarlet Fever Shingles Sinus Problems Hospitalized for any reason
Please list any serious medical condition(s) that you have experienced:
Please list all prescription/over the counter drugs, blood thinners or heart medications you are taking or have taken in the last 30 days:
Are you allergic to any of the following? Please circle all that apply
Aspirin Codeine Erythromycin Latex Sedatives Tetracycline
Dental Anesthetics Jewelry / Metals Penicillin Sulfa Drugs Other Barbiturates
Please list anything additional that causes allergic reactions:
Authorization
I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status.
Patient Name:
Parent or Guardian Signature Date Patient Signature Date
Medical History Update
I have read my medical history dated and confirmed that it states past and present medical condition
Initial Date
I have read my medical history dated and confirmed that it states past and present medical condition
Initial Date
I have read my medical history dated and confirmed that it states past and present medical condition
Initial Date
