Medical History

First Name *

Last Name *

Email *

Date of birth *

Are you under a physician's care? *

Yes

No

Why are you currently under a physicians care?

Have you ever been hospitalized or had a major operation? *

Yes

No

Please explain more about the hospitalization or operation?

Have you ever had a serious injury to your head or neck area? *

Yes

No

Tell us more about your serious injury?

Are you currently taking any type of medication or drugs? *

Yes

No

Please explain in detail which medication, how long ago, dosage, reason, etc

Are you on any type of special diet? *

Yes

No

Please Explain more about your special diet?

Have you ever used or taken Fen-Phen? *

Yes

No

Please Explain

Are you allergic to any type of medication or substances? *

Yes

No

Please tell us about your allergies to medication and what happened?

Please Sign *

Clear

To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or in my medicines, I shall without a doubt inform the dentist in advanced before my next appointment