ODC Medical History

Although dental personal primary treat the area in and around, your mouth is part of your entire body. Health problem that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry your will receive. Thanks you for answering the following question.

Are you allergic to any of the following ?

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Local Anesthetics

Other if yes, please explain:

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

signature of patient, parent or guardian

date

Time

onsite dental care of new england

date : 11/23/2024

medical history

patient name

birth date

Are you under a physician care now ?

YesNo If yes please explain:

Have you ever been hospitalized or had a major operation ?

YesNo If yes please explain:

Have you ever had a serious head or neck injury?

YesNo If yes please explain:

Are you taking any medication pills or drugs ?

YesNo If yes please explain:

Do you take or have you taken Phen-Fen or Redux?

YesNo

Are you on a special diet

YesNo

Do you use tobacco

YesNo

Do you use controlled substances

YesNo

Women : are you

Are you allergic to any of the following ?

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

Comment :

Time

onsite dental care of new england

date : 11/23/2024

medical history

patient name

birth date

Are you under a physician care now ? YesNo If yes please explain:

Have you ever been hospitalized or had a major operation ? YesNo If yes please explain:

Have you ever had a serious head or neck injury? YesNo If yes please explain:

Are you taking any medication pills or drugs ? YesNo If yes please explain:

Do you take or have you taken Phen-Fen or Redux? YesNo

Are you on a special diet YesNo

Do you use tobacco YesNo

Do you use controlled substances YesNo

Women : are you

Are you allergic to any of the following ?

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

Comment :

Are you under a physician care now ?

YesNo If yes please explain:

Have you ever been hospitalized or had a major operation ?

YesNo If yes please explain:

Have you ever had a serious head or neck injury?

YesNo If yes please explain:

Are you taking any medication pills or drugs ?

YesNo If yes please explain:

Do you take or have you taken Phen-Fen or Redux?

YesNo

Are you on a special diet

YesNo

Do you use tobacco

YesNo

Do you use controlled substances

YesNo