Adult Medical-Dental History
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5Adult Medical-Dental History
Adult Medical History
Medical Doctor
Phone Number
Have you been under the care of a Physician in the last 2 years?
Yes
No
If yes, please explain:
Have you been hospitalized or had any surgeries in the last 5 years?
Yes
No
If yes, please explain:
Have you had any adverse reaction to any medications or local anesthetic?
Yes
No
If yes, please explain:
Are you allergic to or had a bad reaction to Latex or Metals?
Yes
No
If yes, please explain:
Due Date
Women: Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Have you taken bone sparing drugs such as Fosamax, Actonel, Boniva or Zometa?
Yes
No
If yes, how long?
A1C #
Date last taken:
INR #
Date last taken:
Are you currently taking any medications?
Yes
No
Do you smoke or use tobacco products?
Yes
Packs per day:
Cans per week
How many years?
No
Do you use alcohol?
How often?
Yes
No
Relationship:
Phone
Emergency Contact
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Parent category: Medical