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Patient Name : Birth Date :
 
      MM/DD/YYYY
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 medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
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
If yes, please explain:
Do you use controlled substances? Yes No
If yes, please explain:
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?
AIDS/HIV Positive   Excessive Bleeding Lung Disease
  Alzheimer’s Disease   Excessive Thirst Mitral Valve Prolapse
  Anaphylaxis   Fainting Spells/Dizziness Pain in Jaw Joints
  Anemia   Frequent Cough Parathyroid Disease
  Angina   Frequent Diarrhea Psychiatric Care
  Arthritis/Gout   Frequent Headaches Radiation Treatment
  Artificial Heart valve   Genital Herpes Recent Weight Loss
  Artificial Joint   Glaucoma Renal Dialysis
  Asthma   Hay Fever Rheumatic Fever
  Blood Disease   Heart Attack/Failure Rheumatism
  Blood Transfusion   Heart Murmur Scarlet Fever
  Breathing Problem   Heart Pace Maker Shingles
  Bruise Easily   Heart Trouble/Disease Sickle Cell Disease
  Cancer   Hemophilia Sinus Trouble
  Chemotherapy   Hepatitis A Spina Bifida
  Chest Pains   Hepatitis B or C Stomach/Intestinal Disease
  Cold Sores/Fever Blisters   Herpes Stroke
  Congenital Heart Disorder   High Blood Pressure Swelling of Limbs
  Convulsions   Hives or Rash Thyroid Disease
  Cortisone Medicine   Hypoglycemia Tonsillitis
  Diabetes   Irregular Heartbeat Tuberculosis
  Drug Addiction   Kidney Problems Tumors or Growths
  Easily Winded   Leukemia Ulcers
  Emphysema   Liver Disease Venereal Disease
  Epilepsy or Seizures   Low Blood Pressure Yellow Jaundice
Have you ever had any serious illness not listed above? Yes No
If yes, please explain:
Comments:

To the best of my knowledge, the question on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patients) health. It is my responsibility to inform the dental office of any changes in medical status.
 
Signature of Patient, Parent, or Guardian Date
 
        MM/DD/YYYY  
 
 
 
 
Manish Sanon, D.D.S., Smile Center
2067 Fairport-Nine Mile Point Road Suite 150
Penfield, NY 14526

Tel: (585) 377-3130
 
   
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