Paent Name: Natural Smiles Densy Eagſt Ml Ho Bir Date: Date Created: Alough dental personnel primaril y eat e area in and around your mou, your mou is a part of your enre body, Heal problems at you may have, or medicaon at you may be tang. Are you under a physician's care now? Hae you eve been hospitalized or had a major opeation? Have you ever had a serious head or neck injury? Areyou taking any medications pills, or drugs? Do you take, or have you taken Phen-Fen or Redux? Have you e.ver taken Fosamax, Boniva, Actonel or any other medications containing bisphospho? Are. you on a special diet? Do you use tobacco? Do you use controlled substances? Women: Are you ... Oves QNo QYes QNo OYes QNo QYes QNo OYes QNo Oves QNo QYes QNo OYes QNo OYes QNo D PregnanTing to get pregnant> □ Nursing> Are you all ergi c to any of e ll owing? □Aspirin D Penicillin □ Metal □ Latex Other? □ Do you have or have you had any of e foll o•Ning? AID S/H N Positive OYes QNo Coisone Medine OYes Alzheimer's Disease QYes QNo Diabet QYes Anaphylaξs OYes QNo Drug Addicti on OYes Anemia Qves QNo EasilyWind QYes Angina Oves QNo Emphysema Oves Arthritis/Gout Qves QNo Epilepsy or Seizur QYes Artificial HeartValve Oves QNo Excessive Bleeding Oves Aificial Joint OYes QNo Excessive irst OYes Asthma QYes QNo Fainting Spells/Dins QYes Blood Disease OYes QNo Frequent Cough OYes BloodTransfusion QYes QNo Frequent Diarrhea QYes Breathing Probl Oves QNo Frequent Headach Oves Bruise Easi Qves QNo Genital Herp QYes Cancer Oves QNo Glaucoma Oves Chemotherapy OYes QNo Hay Fe.ver OYes Chest Pains QYes QNo HeaAacFailure QYes Cold Sores/Fever Bli OYes QNo Hea Murmur OYes Congenital Heart Disord QYes QNo Heart Pacemaker QYes Convulsi ons Oves QNo HeartTroub I e/Disease Oves Have you ever had any serious illness not listed above? OYes QNo Commenʦ: If yes If yes If yes If yes If yes If yes If yes If yes QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo QNo If yes □ codeine D Sulfa Drugs Hemophili a Hepatiti sA Hepatitis B or C Herp High Blood Pressure High Cholesterol Hives or Rash Hypoglyci a Irregular Heabeat Kidney Probl Leukemia Liver Disease Low Blood Press ure. Lung Disease MitraI Valve Prolapse 0 steoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care □Taking oral contraceptiv? □Acrylic D LocalAnestheti OYes QNo RadiationTreatmenʦ OYes QNo QYes QNo RecentWightloss QYes QNo OYes QNo Renal Dialysi s OYes QNo QYes QNo Rheumatic Fever QYes QNo Oves QNo Rheumatism Oves QNo QYes QNo Scarlet Fever QYes QNo Oves QNo Shingl Oves QNo OYes QNo Sickle Cell Disease OYes QNo QYes QNo SinusTroubl QYes QNo OYes QNo Spina Bifida OYes QNo QYes QNo stomach/Intestinal Disease QYes QNo Oves QNo stroke Oves QNo QYes QNo swelling oflimbs QYes QNo Oves QNo yroid Disease Oves QNo OYes QNo Tonsills OYes QNo QYes QNo Tuberculosi s QYes QNo OYes QNo Tumors or Grov,ths OYes QNo QYes QNo Ulcers QYes QNo Oves QNo Venereal Disease Oves QNo YeI low Jaundice. QYes QNo To e best of my owl edge e quesons on is rm have been acruratel y answered. I undersnd at providing incorrect informaon can be dangerous to my {or paent's) heal . It is my responsi bili inform e denl office of any anges in medi cal sbs. Signabre of Paent s Parent or Guardi an: X Date: ____ _