Medications routinely used in dental treatment may interact with both prescription and a number of illegal street drugs. Select the medications you are presently taking, medications you have taken in the past, or medications you have had an adverse reaction to:
Anesthetics, Locally Injected:
Anesthetics, General:
Antacids:
Anti-anxiety Medications:
Anti-depressants:
Antihistamines:
Daily Aspirin Pills:
Blod Pressure Medications:
Codeine Demerol or other Analgesics:
Cortisone or other Steroids:
Coumadin, Heparin, Warfarin or other blood thinners:
Diuretics (water pills):
Fen-phen (Ionimin, adipex, Fastin, phentermine, Pondimin, fenfluramine, Redux, dexfenfluramine:
Heart medications such as Digoxin, Nitroglycerin or Digitalis:
Ibuprofen (Motrin):
Insulin or Diabetes Medications:
Sedatives or Tranquilizers:
Sleeping Pills (Barbiturates):
Thyroid Medication such as Sythroid, Levoxyl or Levothyroxine:
Tylenol (Acetomeniphen):
Adverse reaction to any other medication or drug:
List the other medications you are currently taking and what condition you are taking them for. Include vitamins, supplements, herbs and over the counter medications.
Pharmacy Name:
Phone:
Questions for Women
Are you pregnant?
Are you nursing?
Have you had any surgeries? If so, please describe:
Do you have any other health needs you should bring to our attention?
By submitting this application you are stating that to the best of your knowledge the above information is complete and correct. And that you understand it is your responsibility to inform your doctor if you, or your minor child, have a change in health.
