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HEALTH HISTORY

Patient Name:
_______________________________________
Date: ___________________________
Are you taking any medications, vitamins and/or herbal supplements? Yes No * If yes, please provide a list or write medications on the back of this form. Are you allergic to any antibiotics or any other type of drugs? Yes No If yes, please list ___________________________ _____________________________________________________________________________________________________ Are you allergic to anything else? Yes No * If yes, please explain_______________________________________________ If you have ever taken any of the following medications (or any other medication) for osteoporosis or bone
density problems, please list/circle.


If you have had any of the following, please circle.
Do you have any other serious health concerns or conditions? Yes No *If yes, please explain. _______________________________________________________________________________ Have you ever had to pre-medicate with antibiotics prior to dental treatment? Yes No *If yes, please tell us the name of the antibiotic. ___________________________________________________________ Have you ever had an adverse reaction to a dental procedure? Yes No How do you feel about the appearance of your teeth? ______________________________________________________ What is your primary dental concern? ___________________________________________________________________ Date of last medical examination: ____________ Name & phone of your doctor: ______________________________
Women Only: -------------------------------------------------------------------------------------------------------------------------------------------
Are you pregnant? Yes No Nursing? Yes No I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that
this information will be used by the dentist to help determine appropriate dental treatment. If there is any change in my
medical status, I will inform the dentist. I also understand the use of anesthetic agents embodies a certain risk.
Patient (or Guardian) Signature: _____________________________________________ Date: ________________

Current List of Medications
Name of Medication
Medical Condition Requiring Medication

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Source: http://www.rickjudedmd.com/forms-medical-history.pdf

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