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Patient Information Sheet
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Last Page
Marital Status:
Do you want to share your dental information with anyone (HIPPA)?
Fill in the required fields

Complete Health Dental History

Do we have permission to confirm your appointments with our automated system? *
Haye you ever taken a bisphosphonate medication (Fosamax, Actonel,...)? *
Do you require a premedication (antibiotics) prior o dental treatment? *

Are you allergic to any of the following:

Aspirin *
Latex *
Penicillin *
Codeine *
Clindamycin *
Anesthetics *
Any other Allergies? *

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

Arthritis/ Gout/Rheumatism *
Artificial Joint/ pins *
Diabetes *
Heart Attack/ stroke *
Heart Disease *
Cancer/ chemo/ radiation *
High Blood Pressure *
Osteoporosis *
Tumors/ Growths *
Chronic Inflammation *
Anemia *
Asthma/ Lung Condition *
Drug Addiction *
Glaucoma *
Headache-sf migraines *
Hepatitis *
Hemophilia/ Blood Disorder *
Psychiatric Care *
Thyroid Disease *
ExcessiYe Bleeding *
Aids/HIV posilitive *
Hypoglycemia *
Epilepsy/ Seizures *
Dementia/ Alzheimer's *
Herpes/ Fever Blisters/ shingles *
Pacemaker/ Artificial Valve *
Leukemia *
Pain in Jaw joints *
Tuberculosis *
Stomach/ Intestinal Disease *
Any other serious illness? *
Have you had any major surgeries? *
Are you happy with your smile? *

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.

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