Medical History Form - Foothills Dental of Idaho Falls, ID

Name*

First Last

Date of Birth*

Gender*

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 kneck injury?*

Yes
No

If yes, please explain.

Are you taking any medications, pills or drugs?*

Yes
No

If yes, please explain and list all medications.

Do you take, or have you taken Phen-Fen or Redux?*

Yes
No

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?*

Yes
No

Are you on a special Diet?*

Yes
No

Do you use tobacco?*

Yes
No

Do you use controlled substances?*

Yes
No

Pregnant/Trying to get pregnant?

Yes
No

Nursing?

Yes
No

Taking oral contraceptives?

Yes
No

Are you allergic to any of the following

Aspirin
Penicillin
Third Choice
Codeine
Local Anesthetics
Acrylic
Metal
Latex

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

Have you ever had any serious illness not listed above? If so, them here.

If you could change anything about your smile what would it be?

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.*

Accept

Name

This field is for validation purposes and should be left unchanged.