Dental History FormDental HistoryFormer Dentist *Date of Last X-Rays City, State How often do you brush? Date of last Dental Visit? How often do you floss? Medical HistoryPhysician's Name *Date of last medical exam? *Blood Pressure Have you had any allergic reactions to the following: Local Anesthetics (eg. Novacaine) *YesNoAre Your Currently Under Medical Treatment/ *Describe...Penecillin *YesNoPlease list any others Have you taken Bisphosponate (i.e. Fosamax)? Please list any serious illness or operations *Are you currently taking any medication? If so, please list... Are you taking any type of blood thinner? If yes, please list... Do you use Tobacco ProductsAlcohol(Women Only) Are You: PregnantNursingOn Birth ControlSelect all that apply to your medical information: *Artificial JointsAIDSHIV PositiveHepatitisDiabetesHeart ProblemsLow Blood PressureHigh Blood PressureArtificial Heart ValvesCongenital Heart LesionsCancerChemotherapyRadiation TreatmentTuberculosisAsthmaPacemakerStrokeHeart MurmurMitral Valve ProlapseCirculatory ProblemsRheumatic FeverGlaucomaShortness of BreathBleeding ProblemsAnemiaPsychiatric CareArthritis, RheumatismSinus TroubleUlcerBlood DiseaseEpilepsyEmphysemaFainting or DizzinessKidney DiseaseLiver DiseaseThyroid ProblemsVenereal DiseaseJaw, Head or Neck InjuriesSwelling of Feet/AnklePlease list any other medical conditions or concerns: VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
