Adult Health History Form Your overall health as well as any medications which you take could have an important inter-relationship with the dental care you receive. Please answer each of the following questions completely. Patient Medical History 1. Are you under medical treatment now? YesNo2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? YesNo3. Are you taking any medication(s) including non-prescription medicine? YesNo4. Have you ever taken Fen-Phen/Redux? YesNo5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates? YesNo6. Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours? YesNo7. Do you use tobacco? YesNo8. Do you use controlled substances? YesNo9. Are you wearing contact lenses? YesNo10. Do you have or have you had any of the following? Check all the apply High Blood PressureHeart DiseaseChest PainsHeart AttackCardiac PacemakerEasily Winded Rheumatic FeverHeart MurmurStrokeSwollen AnklesHay Fever/AllergiesAngina Fainting/SeizuresFrequently TiredTuberculosisAsthmaAnemiaRadiation TherapyLow Blood Pressure GlaucomaEmphysemaEpilepsy/ConvulsionsCancerRecent Weight LossLeukemiaArthritis Liver DiseaseDiabetesJoint ReplacementHeart TroubleKidney DiseaseHepatitis/JaundiceRespiratory Problems AIDS or HIV InfectionSTDMitral Valve ProlapseThyroid ProblemStomach Troubles/UlcersOther11. Are you allergic to or have you had any reactions to the following? Check all the apply Local Anesthetics (e.g. Novocain)IodineAspirinPenicillin or any other AntibioticsSulfa Drugs BarbituratesAny Metals (e.g. nickel, mercury, etc.)Latex RubberSedativesOther 12. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)? YesNo13. Are You a Woman? YesNo13a. Are you pregnant or think you may be pregnant YesNo13b. Are you nursing? YesNo13c. Are you taking oral contraceptives? YesNoPatient Dental History1. Do your gums bleed while brushing or flossing? YesNo2. Are your teeth sensitive to hot or cold liquids/foods? YesNo3. Are your teeth sensitive to sweet or sour liquids/foods? YesNo4. Do you have any sores or lumps in or near your mouth? YesNo5. Do you feel pain to any of your teeth? YesNo6. Have you had any head, neck or jaw injuries? YesNo7. Do you have frequent headaches? YesNo8. Do you clench or grind your teeth? YesNo9. Have you ever had any orthodontic treatment? YesNo10. Have you ever had any difficult extractions in the past? YesNo11. Have you ever had any prolonged bleeding following extractions? YesNo12. Have you ever received oral hygiene instructions regarding the care of your teeth and gums? YesNo13. Do you bite your lips or cheeks frequently? YesNo14. Do you like your smile? YesNo15. Do you wear dentures or partials? YesNo16. Have you ever experienced any of the following problems in your jaw? Check all the apply ClickingPain (joint, ear, side of face)Difficulty in opening or closingDifficulty in chewingAuthorization and ReleaseI certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.