New Patient Form Submission - Tenniswood Dental Associates

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Tenniswood Dental Associates

Dentist in Okeechobee, FL

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TENNISWOOD DENTAL ASSOCIATES

Medical History Form
Patient Name:
Birth Date:
Date Format: MM slash DD slash YYYY
Date:
Date Format: MM slash DD slash 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
Have you ever been hospitalized or had a major operation?
- YES
- No
If yes
Have you ever had a serious head or neck injury?
- YES
- No
If yes
Do you take, or have taken, Phen-Fen or Redux?
- YES
- No
If yes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
- YES
- No
If yes
Do you use controlled substances?
- YES
- No
If yes
Have you taken any steroids in the last two years? (Ex: Prednisone, Cortisone)
- YES
- No
If yes
Any tobacco usage? (Cigarettes, Chew Dip, Vape) If yes: type, Amount per Day, Duration
- YES
- No
If yes
Are you taking any medications, pills, or drugs?
- YES
- No
If yes
Please list any other medications here:
Women: Are you…
- Pregnant
- Nursing
- Taking oral contraceptives
- Hormonal Replacements
Are you allergic to any of the following?
- Aspirin
- Penicillin
- Codeine
- Acrylic
- Metal
- Latex
- Sulfa Drugs
- Local Anesthetics

Any other allergies not listed above?
Do you HAVE or have you HAD, any of the following?
- Rheumatic Fever/Rheumatic Heart Disease
- Excessive Bleeding
- Kidney/Urinary Disorders
- Stroke
- Heart Attack/ Heart Failure
- Heart Defect
- Thyroid/Parathyroid Disease
- Diabetes
- Blood Disorder (Anemia, Leukemia, Sickle Cell Disease)
- Arthritis
- Dermatologic/Skin Disorders
- Blood Transfusion
- Cancer/Tumor
- Osteoporosis
- Pain in Jaw Joints
- Heart Disease
- AIDS/HIV Positive
- Chemotherapy/Radiation
- Hepatitis A,B,C.D
- Drug Addiction
- Respiratory/Lung Disease
- High or Low Blood Pressure
- Epilepsy/Seizures/Fainting Spells
- Artificial Joints/Heart Valve
- Hypoglycemia (Low Blood Sugar)
- Sinus Trouble
- Stomach, Intestine or Liver Disorders
- Frequent Headaches/Migraine
- Chest Pains/Angina
- Tuberculosis
- Cold Sores/Fever Blisters
- Heart Murmur/Mitral Valve
- Congenital Heart Disorder
- Prolapse/Heart Defect
- Emotional Conditions (Depression, PTSD, Anxiety)
- Heart Pacemaker
- Hay fever
- Asthma
- Seasonal Allergies
Have you ever had any serious illness not listed above?
- Yes
- No
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 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
Date Format: MM slash DD slash YYYY

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Tenniswood Dental Associates 208 NE 3rd Street
Okeechobee, Fl 34972

(863) 763-3909

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