New Patient Medical History Form Citrus View Dental New Patient Medical History (Form 2 of 2)Patient Name* Patient Date of Birth* MM DD YYYY*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 medication that you may be taking, could have an important interrelationship with the dentist you will receive. Thank you for answering the following questions.Are you under a physician's care now?Please SelectYesNoIf Yes, Please Explain:Have you ever been hospitalized or had a major operation?Please SelectYesNoIf Yes, Please Explain:Have you ever had a serious head or neck injury?Please SelectYesNoIf Yes, Please Explain:Are you taking any medications, pills or drugs?Please SelectYesNoIf Yes, Please Explain:Do you use tobacco?*Please SelectYesNoHave you taken Phen-Phen or Redux?*Please SelectYesNoAre you on a special diet?*Please SelectYesNoDo you use controlled substances?*Please SelectYesNoHave you taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*Please SelectYesNoAre you male or female?Please SelectMaleFemaleAre you taking oral contraceptives?Please SelectYesNoAre you nursing?Please SelectyesnoPlease select if you are allergic to any of the following: Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa drugs OtherPlease list all additional allergies*Please check if you have, or have had, any of the following: Aids/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophillia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Colesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Wight Loss Renal Dyalysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow JaundiceHave you had any serious illness not listed above?Please SelectYesNoIf Yes, Please Explain:Please type your name below if, to the best of your knowledge, the questions on this form have been accurately answered and acknowledge that you understand that providing incorrect information can be dangerous to your health of the patient's health and that it is your responsibility to inform the dentist of any changes in medical status. First Last Patient/Guardian Signature (Office Use Only, Please Sign in Person During Your Visit)Date* MM DD YYYYEmailThis field is for validation purposes and should be left unchanged.