MEDICAL HISTORY
Although dental personnel primarily treat the area in and around your mouth, your mouth is a 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 dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?
YesNo
Have you ever been hospitalized or had a major operation?
YesNo
Have you ever had a serious head or neck injury?
YesNo
Are you taking any medications, pills or drugs?
YesNo
Do you take, or have you taken, Phen-Fen or Redux?
YesNo
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
YesNo
Are you on a special diet?
YesNo
Do you use tobacco?
YesNo
Have you been out of the country within the last 6 months?
YesNo
Are you allergic to the following:
Asprin
Penicillin
Codeine
Acrylic
Metals
Latex
Sulfa Drugs
Local Anesthetics
Do you use controlled substances?
YesNo
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Cortisone Medicine
Hemophilia
Radiation Treatment
Alzheimer's Disease
Diabetes
Hepatitis A
Recent Weight Loss
Anaphylaxis
Drug Addiction
Hepatitis B or C
Renal Dialysis
Anemia
Easily Winded
Herpes
Rheumatic Fever
Angina
Emphysema
High Blood Pressure
Rheumatism
Arthritis/Gout
Epilepsy or Seizure
High Cholesterol
Scarlet Fever
Artificial Heart Valve
Excessive Bleeding
Hives or Rash
Shingles
Artificial Joint
Excessive Thirst
Hypoglycemia
Sickle Cell Disease
Asthma
Fainting Spells/Dizziness
Irregular Heartbeat
Sinus Trouble
Blood Disease
Frequent Cough
Kidney Problems
Spina Bifida
Blood Transfusion
Frequest Diarrhea
Leukemia
Stomach/Intestinal Disease
Breathing Problems
Frequent Headaches
Liver Disease
Stroke
Bruise Easily
Genital Herpes
Low Blood Pressure
Swelling of Limbs
Cancer
Glaucoma
Lung Disease
Thyroid Disease
Chemotherapy
Hay Fever
Mitral Valve Prolapse
Tonsillitis
Chest Pains
Heart Attack/Failure
Osteoporosis
Tuberculosis
Cold Sores/Fever Blisters
Heart Murmur
Pain in Jaw Joints
Tumors or Growths
Congenital Heart Disorder
Heart Pacemaker
Parathyroid Disease
Ulcers
Convulsions
Heart Trouble/Disease
Psychiatric Care
Venerial Disease
Yellow Jaundice
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New patients can make their appointments at our dental office in West Bloomfield, Michigan, even more relaxing and enjoyable when they complete our patient forms. By filling out these forms before your appointment with our dentist, your check-in to our practice can run more quickly. Call Dr. Shiva Hogugi if you have any questions about our new patient forms.