WELCOME
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we’ll be glad to help you. We look forward to working with you in maintaining your dental health.
PATIENT INFORMATION
Physician’s name Phone
Date of last visit Have you had any serious illnesses or operations? YN
If yes, please describe
Are you in good health? YN
Has there been any change in your general health in the past year? YN
Are you currently under physician care? YN
If yes, describe
Have you ever had a blood transfusion? YN
If yes, give approximate dates
Have you ever taken Fen-Phen/Redux? YN
Women: Are you pregnant? YN
Nursing YN
Taking Birth Control Pills? YN
Are you using any of the following?
Antibiotics? YN
Anticoagulants (blood thinners)? YN
Aspirin or drugs such as Motrin, Aleve, Ibuprofen? YN
High Blood Pressure medications? YN
Steroids (Cortisone, etc.)? YN
Weight loss medications (Fen-Phen)? YN
Tranquilizers and/or antidepressants? YN
Insulin or Oral Anti-Diabetic drugs? YN
Digitalis, Inderal, Nitroglycerin or other heart drug? YN
Recreational Drugs? YN
Are you taking or have you ever taken Bisphosphonates (such as Fosamax or Actonel for osteoporosis, or chemotherapy for multiple Myeloma, etc.)? YN
Please list any and all medications taken, including prescription and over-the-counter medications, herbal or holistic remedies, vitamins or minerals:
Indicate which of the following you have had or have at present: