Medical History Forms | Chico Dental Care

Jaw Pain

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Nervous Problems

Yes No

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Respiratory Disease

Yes No

Scarlet Fever

Yes No

Shortness of Breath

Yes No

Sinus Trouble

Yes No

Skin Rash

Yes No

Special Diet/Weight Loss

Yes No

Stroke

Yes No

Swollen Feet or Ankles

Yes No

Swollen Neck Glands

Yes No

Thyroid Problems

Yes No

Tobacco Use

Yes No

Tonsillitis

Yes No

Tumors or Growths

Yes No

Tuberculosis

Yes No

Ulcer

Yes No

Are you currently taking any blood thinners such as Coumadin, Warfarin, Plavix, aspirin, etc.?

Yes No

If yes, please list which of these meds you have taken/are taking below:

Have you ever taken or are you currently taking any bone density medications (bisphosphonates) such as Actonel, Boniva, Fosamax, Zometa, etc.?

Yes No

If yes, please list which of these meds you have taken/are taking below: