Medical History

PATIENT NAME:

*

Birth Date:

*

Are you under a physician's care now?:

*

Yes

No

Have you ever been hospitalized or had a major operation?:

*

Yes

No

Have you ever had a serious head or neck injury?:

*

Yes

No

Are you taking any medications, pills, or drugs?:

*

Yes

No

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

Taking oral contraceptives?:

Yes

No

Nursing?:

Yes

No

Aspirin

Penicillin

Codeine

Local Anesthetics

Acrylic

Metal

Latex

Sulfa drugs

Ballard Dental Associates

Medical History

Quick Links

Let's Get Social!

Get in touch!