MEDICAL HISTORY

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

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Woman: Are you

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Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalLatexLocal AnestheticsOther

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

AIDS/ HIV PositiveAlzheimer's DiseaseAnaphylaxisAcrylicAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpliepsy or SeziuresExcessive BleedingExcessive ThirstFainting Spells/ DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGential HerpesGlaucomaHay FeverHeart Attack/FailureHemophillaHepatitis AHepatitis B or CHerpesHigh Blood PressureHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapsePain in Jaw JointsParathyroid DiseaseRenal DialysisRheumatic FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/ Intestinal DiseStrokeSwelling of LimbsThyroid DiseaseTonsilitisLung DiseaseTuberculosisTumors or GrowthUlcers

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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 my medical status.