JAMES HEATON DDS, FAGD

Smiles of Chandler, 4940 W Ray Rd #8

Chandler, AZ - 85226, USA

(480) 899-9484

Medical History

Patient Name:
Birth Date:
Phone:
Email:

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

Are you under a physician's care now?
If Yes
Have you ever been hospitalized or had a major operation?
If Yes
Have you ever had a serious head or neck injury?
If Yes
Do you take, or have you taken, Phen-Fen or Redux?
If Yes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
If Yes
Are you on a special diet?
Do you use tobacco?

Women: Are you ...

Are you allergic to any of the following?

If Yes
Do you use controlled substances?
If Yes

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

AIDS/ HIV Positive
Alzheimer
Anaphylaxis
Anemia
Angina
Arthritis / Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores / Fever Blisters
Congenital Heart Disorder
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
Hepatitis B or C
Herpes
High Blood Pressure B
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
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
If Yes
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.

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Signature of Parent or Guardian:

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