Time

onsite dental care of new england

date : 01/19/2022

medical history

patient name

birth date

Although dental personal primary treat the area in and around, your mouth is part of your entire body. Health problem that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry your will receive. Thanks you for answering the following question.

Are you under a physician care now ?
YesNo If yes please explain:

Have you ever been hospitalized or had a major operation ?
YesNo If yes please explain:

Have you ever had a serious head or neck injury?
YesNo If yes please explain:

Are you taking any medication pills or drugs ?
YesNo If yes please explain:

Do you take or have you taken Phen-Fen or Redux?
YesNo

Are you on a special diet
YesNo

Do you use tobacco
YesNo

Do you use controlled substances
YesNo

Women : are you

pregnant/trying to get pregnant ? Nursing?
taking oral contraceptives?

Are you allergic to any of the following ?

Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Other  if yes, please explain:

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

AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed above? Yes No If yes, Please explain:

Comment :

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

signature of patient, parent or guardian
date