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Download MedIcJaJ History - Dupont Dental Office
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MedIcJaJ History _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: Physician's Name: Physician's Phone: _ Dale of last vis~: Please list any medic@lions/yi!aminslsupp1emvnls that you currently \!Ike: Have you ever or are you currently taking any bisphosphonate medication? (Fosimax. Actonel, Boniva etc... ) DYes D No Check all that apply D Abnonnal Bleeding o D Acid Reflux D Fever Blisters D Snofing D Alcohol Abuse D Frequent Headaches D Stroke D Allergies D Glaucoma D Thyroid Problems D Anemia D Hay Fever D Tuberculosis D Angina D Heart Problems o Ulcers D Arthritis D Heart Surgery D Venereal Disease D Artificial Heart Valve D Hemophilia D ArtifICial Joint D Hepat~is D Aspirin D Asthma D High Blood Pressure D Codeine D Autoimmune Disorders D HIV/AIDS D Dental Anesthetics D Blood Transfusion D Kidney Problems D Erythromycin o Cancer D Liver Disease D o D Low Blood Pressure D Metals o Colitis D M~I Valve Prolapse D Penicillin D Congenital Heart Defect D Pace Maker D Cosmetic Surgery D Psychiatric Problems D Diabetes D Radiation Therapy D D D D Difficulty Breathing D Rheumatic Fever D Drug Abuse D Seizures o Pregnancy D Emphysema D Shingles D Birth Control Pills D Epilepsy D Sickle Cell Disease D Nursing Chemotherapy Fainting Spells D Sinus Problems Allergie. Latex Sulfa Drugs Tetracycline Other Women
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