New Patient Form Submission Page Please fill out the items below Step 1 of 2 50% TENNISWOOD DENTAL ASSOCIATES Medical History FormPatient 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 yesHave you ever been hospitalized or had a major operation? YES No If yesHave you ever had a serious head or neck injury? YES No If yesDo you take, or have taken, Phen-Fen or Redux? YES No If yesHave you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? YES No If yesDo you use controlled substances? YES No If yesHave you taken any steroids in the last two years? (Ex: Prednisone, Cortisone) YES No If yesAny tobacco usage? (Cigarettes, Chew Dip, Vape) If yes: type, Amount per Day, Duration YES No If yesAre you taking any medications, pills, or drugs? YES No If yesPlease 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