Medical History (Hogansville)

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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 medications 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 currently under a physician's care?

Yes

No

If yes, what is their name/practice?

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 ever taken, Phen-Fen, or Redux?

Yes

No

If yes, please explain.

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing biphosphonates?

Yes

No

If yes, please explain.

Are you are on a special diet?

Yes

No

If yes, please explain.

Do you use tobacco?

Yes

No

Do you use controlled substances?

Yes

No

Women: Are you pregnant/trying to get pregnant?

Yes

No

Women: Are you taking oral contraceptives?

Yes

No

Women: Are you nursing?

Yes

No

Are you allergic to any of the following?

Please list any other allergies

Do you have, or have you had any of the following?

Have you had any serious illness not listed?