Wesley A. Harper, D.D.S., P.C.
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 under a physician care now?
If Yes, explain:
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury
Are you taking any medications, pills or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Women: Are you
Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Are you allergic to any of the following?
Do you have, or have you had, any of the following?
Hepatitis B or C
High Blood Pressure
Epilepsy or Seizures
Hives or Rash
Sickle Cell Disease
Artificial Heart Valve
Swelling of limbs
Low Blood Pressure
Mitral Valve Prolapse
Pain in Jaw Joints
Tumors or Growths
Cold Sores/Fever Blisters
Congenital Heart Disorder
Heart Pace Maker
Recent Weight Loss
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.
SIGNATURE OF PATIENT, PARENT OR GUARDIAN__________________________________ Date: