Medical History Form

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or mdication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Name Birthday

Are you under a physician's care now? Yes No If yes, please explain

Have you ever been hospitalized or had a major operation? Yes No If yes, please explain

Have you ever had a serious head or neck injury? Yes No If yes, please explain

Are you taking any medications, pills, or drugs? Yes No If yes, please explain

Do you take, or have you taken, Phen-Fen or Redux? Yes No If yes, please explain

Are you on a special diet? Yes No If yes, please explain

Do you use tobacco? Yes No

Do you use controlled substances? Yes No

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?

Have you ever had any serious illness not listed above? Yes No If yes, please explain

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.

Signature of Patient, Parent, or Guardian: Email:

We appreciate your time in updating your medical history. This information is pertinent in rendering dental treatment and will be held strictly confidential.

Hi-Tech Family Dentistry

Mark R. Morin DDS, PC

Medical History Form