Ireland Mercho Dental Patient Medical History Patient Name Birth Date Today's Date Section 1 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: Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No If Yes please explain: Are you on a special diet? Yes No Do you use tobacco? Yes No Women: are you... Pregnant/Trying to get pregnant? Nursing? Taking oral contrceptives? Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics Other allergies? Yes No If Yes, please explain: Do you use controlled substances? Yes No If Yes, please explain: Do you have, or have you had, any of the following: Please check any that apply AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Athritis/Gout Artificial Heart Valve Artifical Joint Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disease Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitus B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Problems Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed Yes No If Yes, please explain: Comments 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 my patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. Signature of Patient, Parent or Guardian: Date Submit
