Mitral valve prolapse
Artificial heart valves
Congestive heart failure
Coronary artery disease
Damaged heart valves
Low blood pressure
High blood pressure
Congenital heart defects
Rheumatic heart disease
If yes, date:
AIDS or HIV infection
Chest pain upon exertion
Diabetes Type I or II
Hepatitis, jaundice or
Fainting spells or seizures
If yes, Specify:
Mental health disorders
Type of infection:
Persistent swollen glands
Severe or rapid weight loss
Sexually transmitted disease
(Check DK if you Don’t Know the answer to the question)
Are you taking or scheduled to begin taking either
of the medications, alendronate (Fosamax®) or
risedronate (Actonel®) for osteoporosis or
Since 2001, were you treated or are you presently
scheduled to begin treatment with the intravenous
bisphosphonates (Aredia® or Zometa®) for bone
pain, hypercalcemia or skeletal complications
resulting from Paget’s disease, multiple
myeloma or metastatic cancer?
Date Treatment began:
Joint Replacement. Have you had an orthopedic total joint (hip, knee,
elbow, finger) replacement?
Date: If yes, have you had any complications?
Allergies - Are you allergic to or have you had a reaction to:
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Codeine or other narcotics
Please mark (X) your response to indicate if you have or have not had any of the following disease or problems.
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
(Circle one) VERY / SOMEWHAT / NOT INTERESTED
Do you drink alcoholic beverages?
If yes, how much alcohol did you drink in the last 24 hours?
If yes, how much do you typically drink in a week?
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history
and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been
answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or
omissions that I have made in the completion of this form.
Signature of Patient/Legal Guardian: Date:
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Name of physician or dentist making recommendation: Phone:
Do you have any disease, condition, or problem not listed above that you think I should know about?
WOMEN ONLY Are you:
Number of weeks: _____________
Taking birth control pills or hormonal replacements?