Medical History

River City Dental



Birth Date (MM/DD/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 , please explain:
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 taken, Phen-Fen or Redux?
 Yes No
If yes , please explain:
Are you 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
Taking oral contraceptives?
 Yes No
 Yes No

Are you allergic to any of the following ?

 Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other
If yes, please explain:

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

  • AIDS/HIV Positive  Yes No
  • Alzheimer's Disease  Yes No
  • Anaphylaxis  Yes No
  • Anemia  Yes No
  • Angina  Yes No
  • Arthritis/Gout  Yes No
  • Artificial Heart Valve  Yes No
  • Artificial Joint  Yes No
  • Asthma  Yes No
  • Blood Disease  Yes No
  • Blood Transfusion  Yes No
  • Breathing Problem  Yes No
  • Bruise Easily  Yes No
  • Cancer Yes No
  • Chemotherapy  Yes No
  • Chest Pains  Yes No
  • Cold Sores/Fever Blisters  Yes No
  • Congenital Heart Disorder  Yes No
  • Convulsions  Yes No
  • Cortisone Medicine  Yes No
  • Diabetes  Yes No
  • Drug Addicition  Yes No
  • Easily Winded  Yes No
  • Emphysema  Yes No
  • Epilepsy or Seizures  Yes No
  • Excessive Bleeding  Yes No
  • Excessive Thirst  Yes No
  • Fainting Spells/Dizziness  Yes No
  • Frequent Cough  Yes No
  • Frequent Diarrhea  Yes No
  • Frequent Headaches  Yes No
  • Genital Herpes  Yes No
  • Glaucoma  Yes No
  • Hay Fever  Yes No
  • Heart Attack/Failure  Yes No
  • Heart Murmur  Yes No
  • Heart Pace Maker  Yes No
  • Heart Trouble/Disease  Yes No
  • Hemophilia  Yes No
  • Hepatitis A  Yes No
  • Hepatitis B or C  Yes No
  • Herpes  Yes No
  • High Blood Pressure  Yes No
  • Hives or Rash  Yes No
  • Hypoglycemia  Yes No
  • Irregular Heartbeat  Yes No
  • Kidney Problems  Yes No
  • Leukemia  Yes No
  • Liver Disease  Yes No
  • Low Blood Pressure  Yes No
  • Lung Disease  Yes No
  • Mitral Valve Prolapse  Yes No
  • Pain in Jaw Joints  Yes No
  • Parathyroid Disease  Yes No
  • Psychiatric Care  Yes No
  • Radiation Treatments  Yes No
  • Recent Weight Loss  Yes No
  • Renal Dialysis  Yes No
  • Rheumatic Fever  Yes No
  • Rheumatism  Yes No
  • Scarlet Fever  Yes No
  • Shingles  Yes No
  • Sickle Cell Disease  Yes No
  • Sinus Trouble  Yes No
  • Spina Bifida  Yes No
  • Stomach/Intestinal Disease  Yes No
  • Stroke  Yes No
  • Swelling of Limbs  Yes No
  • Thyroid Disease  Yes No
  • Tonsillitis  Yes No
  • Tuberculosis  Yes No
  • Tumors or Growths  Yes No
  • Ulcers  Yes No
  • Venereal Disease  Yes No
  • Yellow Jaundice  Yes No
  • High Cholesterol  Yes No
  • Osteoporosis  Yes No
Have you ever had any serious illness not listed above?
 Yes No
If yes, please explain
Have you ever taken fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
 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 responsibility to inform the dental office of any changes in medical status.

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