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Hours & Contact
Mon:
11:00am - 8:00pm
Tues & Sun:
Closed
Wed - Thurs:
10:00am - 5:00pm
Frid:
9:00am - 3:00pm
Sat:
Appointment Only
Have a question? Give us a call!
(201) 845-5533
(201) 845-5533
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Search
Medical History Form
Patient Name
Email
Birth Date
Are you under a physician's care now?
- None -
Yes
No
If yes
Have you ever been hospitalised or had a major operation?
- None -
Yes
No
If yes
Have you ever had a serious head or neck injury?
- None -
Yes
No
If yes
Are you taking any medications, pills, or drugs?
- None -
Yes
No
If yes
Do you take, or have taken, Phen-Fen or Redux?
- None -
Yes
No
If yes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
- None -
Yes
No
If yes
Are you on a special diet?
- None -
Yes
No
If yes
Do you use tobacco?
- None -
Yes
No
If yes
Do you use controlled substances?
- None -
Yes
No
If yes
Women: Are you
Pregnant/Trying to get pregnant
Nursing
Taking oral contraceptives
Are you allergic to any of the following?
Aspirin
Penicilin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
Other
If other, please specify
Do you have, or have you had, any of the following?
AIDS/HIV Positive
- None -
Yes
No
Alzheimer's Disease
- None -
Yes
No
Anaphylaxis
- None -
Yes
No
Anemia
- None -
Yes
No
Angina
- None -
Yes
No
Arthritis/Gout
- None -
Yes
No
Artificial Heart Valve
- None -
Yes
No
Artificial Joint
- None -
Yes
No
Asthma
- None -
Yes
No
Blood Disease
- None -
Yes
No
Blood Transfusion
- None -
Yes
No
Breathing Problems
- None -
Yes
No
Bruise Easily
- None -
Yes
No
Cancer
- None -
Yes
No
Chemotherapy
- None -
Yes
No
Chest Pains
- None -
Yes
No
Cold Sores/Fever Blisters
- None -
Yes
No
Congenital Heart Disorder
- None -
Yes
No
Convulsions
- None -
Yes
No
Cortisone Medicine
- None -
Yes
No
Diabetes
- None -
Yes
No
Drug Addiction
- None -
Yes
No
Easily Winded
- None -
Yes
No
Emphysema
- None -
Yes
No
Epilepsy or Seizures
- None -
Yes
No
Excessive Bleeding
- None -
Yes
No
Excessive Thirst
- None -
Yes
No
Fainting Spells/Dizziness
- None -
Yes
No
Frequent Cough
- None -
Yes
No
Frequent Diarrhea
- None -
Yes
No
Frequent Headaches
- None -
Yes
No
Genital Herpes
- None -
Yes
No
Glaucoma
- None -
Yes
No
Hay Fever
- None -
Yes
No
Heart Attack/Failure
- None -
Yes
No
Heart Murmur
- None -
Yes
No
Heart Pacemaker
- None -
Yes
No
Heart Trouble/Disease
- None -
Yes
No
Hemophilia
- None -
Yes
No
Hepatitis A
- None -
Yes
No
Hepatitis B or C
- None -
Yes
No
Herpes
- None -
Yes
No
High Blood Pressure
- None -
Yes
No
High Cholesterol
- None -
Yes
No
Hives or Rash
- None -
Yes
No
Hypoglycemia
- None -
Yes
No
Irregular Heartbeat
- None -
Yes
No
Kidney Problems
- None -
Yes
No
Leukemia
- None -
Yes
No
Liver Disease
- None -
Yes
No
Low Blood Pressure
- None -
Yes
No
Lung Disease
- None -
Yes
No
Mitral Valve Prolapse
- None -
Yes
No
Osteoporosis
- None -
Yes
No
Pain in Jaw Joints
- None -
Yes
No
Parathyroid Disease
- None -
Yes
No
Psychiatric Care
- None -
Yes
No
Radiation Treatment
- None -
Yes
No
Recent Weight Loss
- None -
Yes
No
Renal Dialysis
- None -
Yes
No
Rheumatic Fever
- None -
Yes
No
Rheumatism
- None -
Yes
No
Scarlet Fever
- None -
Yes
No
Shingles
- None -
Yes
No
Sickle Cell Disease
- None -
Yes
No
Sinus Trouble
- None -
Yes
No
Spina Bifida
- None -
Yes
No
Stomach/Intestinal Disease
- None -
Yes
No
Stroke
- None -
Yes
No
Swelling of Limbs
- None -
Yes
No
Thyroid Disease
- None -
Yes
No
Tonsillitis
- None -
Yes
No
Tuberculosis
- None -
Yes
No
Tumors or Growths
- None -
Yes
No
Ulcers
- None -
Yes
No
Venereal Disease
- None -
Yes
No
Yellow Jaundice
- None -
Yes
No
Have you ever had any serious illness not listed above?
- None -
Yes
No
If yes, please specify:
Comments:
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.
Date
Signature
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