Western New York Dental Group Forms Portal
Western New York Dental Group Forms Portal

Medical History Form
So we may provide you with the best possible care, it is important that you tell all dental personnel involved in your treatment about the general state of your health. This information is, of course, confidential. Please answer the following items as completely as possible. Click the 'Submit' button at the bottom of the form when you are finished. Thank you!

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If completing this form for another person,
what is your relationship to that person?

 
Medical History
Have you or anyone in your family had an adverse reaction
to local anesthesia, IV sedation, or general anesthesia?

 
Is there anything you would like to discuss
privately with the Dentist?

 
List all medications prescribed by your physician
including birth control pills, vitamins, herbal
supplements, natural products, over-the-counter
drugs taken routinely, and controlled substances.
Include dosages if available.

 
Allergies/Sensitivities

 
Are you allergic, sensitive, or ever had an adverse
reaction to: (Check all that apply or check none)

 
Do you have, or have you ever had any of the
following: (Check all that apply)

 
Congenital Heart Disease (CHD)

 
Hepatitis

 
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Bisphosphonates

 
Have you ever or are you currently taking or
scheduled to begin taking any of the medications
alendronate (Fosamax®), risedronate (Actonel®)
or ibrandronate (Boniva®) for osteoporosis or
Paget's disease?

 
Since 2001, were you treated or are you presently
scheduled to begin treatment with intravenous
bisphosphonates (Aredia® or Zometa®) for bone
pain, hypercalcemia, or skeletal complications
resulting from Paget’s disease, multiple myeloma
or metastatic cancer?

 
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Have you ever used or currently use
tobacco products?

 
Have you had any other serious illness,
hospitalization, or accident?

 
Women:
Are you pregnant or suspect that you may be?

 
I understand the above information is necessary
to provide me with dental care in a safe and
efficient manner. I have answered all questions
to the best of my knowledge. Should further
information be needed, you have my permission
to ask the respective health care provider or
agency,who may release such information to you.
I will notify the doctor of any changes in my
health or medication.

 
Submit Form

 
Submit Completed Form