Medical History

Medical History
* required field

Medical History

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?

Have you ever been hospitalized or had a major operations?

Have you ever had a serious head or neck injury?

Do you need to take pre-medication for dental treatment?

Are you taking any medications, pills, or drugs?

Have you ever taken Fosamax, Bonica, Actonel or any other medications contaning bisphosphonates?

Are you on a special diet?
Do you use tobacco?


Are you taking contraceptives?

Are you pregnant/trying to get pregnant?
Are you nursing?


Are you allergic to any of the following?

Do you use controlled substances?

Major Illnesses

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

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.

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Maplewood Dental Associates

  • 1736 Cope Ave. E., Maplewood, MN 55109Phone: 651-770-3831Fax: 651-770-9645