Patient Medical History - Legacy Dental Franklin

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or the medications or vitamins that you may be taking, could have an important interrelationship with the dentistry that you will receive.

following? last you

What is your family doctor's name?

Have you been in the hospital/had a major operation in the last five years?

Have you had a serious head/neck injury?

Yes
No

Do you use tobacco, tobacco products or vaping?

Yes
No

Please list any medications or vitamins:

Have you ever taken Fosamax, Boniva, Actonel or any other Bisphosphonates for your bones?

Yes
No

FOR WOMEN ONLY: Are you pregnant/trying to get pregnant/in fertility?

Yes
No

Taking oral contraceptives?

Yes
No

Are you allergic to any of the following?

Mark yes if you have ever had any of the following- Circle One

Other Conditions/Comments:

Parent Signature:

Clear Signature

Date: