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Merrimack Valley Dental Care
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+1 (978) 454-8221
Are you currently being treated by a physician for a specific condition?
If so, please tell us about your treatment
Have you recently been hospitalized or had a major operation?
If so, please tell us about the hospitalization
Have you ever had a serious head or neck injury?
If so, please tell us about the head/neck injury
Are you taking any medications, pills, or drugs?
Please list all medications and dosage
Are you on a special diet?
Please tell us about your diet
Do you use tobacco?
Please tell us how often and what type of tobacco consumption
Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.
Have you ever been advised that you require antibiotics prior to a dental appointment?
Please tell us about the antibiotics
Do you take, or have you taken, PhenFen or Redux?
If so, please tell us about your PhenFen/Redux usage
Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates?
If so, please tell us about your bisphosphonate usage
Have you recently used controlled substances?
If so, please tell us which controlled substances and amount/frequency
Have you recently consumed alcohol?
Please tell how much alcohol and how recently
Please answer if filling this form out on the day of your appointment
Women (Please check all that apply)
Trying to get pregnant
Taking oral contraceptives
None of the above
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic)
None of the Above
Do you have, or have you ever had any of the following medical conditions? (Please select all that apply)
Cold Sores/Fever Blisters
High Blood Pressure
Hives or Rash
Recent Weight Loss
Arthritis or Gout
Congenital Heart Problems
Heart Valve or Pacemaker
Ulcers or GI Problems
Heart Attack/Heart Failure
Hepatitis (B or C)
Low Blood Pressure
Mitral Valve Prolapse
Sickle Cell Disease
Swelling of Limbs
Dizziness or Fainting
Epilepsy or Seizures
Jaw Joint Pain
Tumor or Growth
No to All
Do you have any condition or problem, not listed, which we should know about? 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.
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