Medical History Form Siva Forms

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?

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 you 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

Are you on a special diet?

Yes No

Do you use tobacco?

Yes No

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:

Use your mouse cursor or the tip of your finger to sign below

Date:

Signature of Parent or Guardian:

Use your mouse cursor or the tip of your finger to sign below

Date: