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Des Moines River Dental Care

Your Carlisle Iowa Area Hometown Dentist

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Health history

Please submit the electronic form below, or you may print this FORM and bring it into the office.

Date of Birth Have you had any dental complications in the past? YesNo Have you had orthodontics? YesNo Have you ever been treated for gum disease? YesNo Is there anything you would change about the appearance of your teeth or smile? YesNo Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? YesNo Has a physician recommended you take a Pre-Medication (antibiotics) for dental treatment? YesNo have you ever had a reaction after receiving dental anesthetic? YesNo Have you been hospitalized within the past year? YesNo Women: Are you... Pregnant NursingTaking oral contraceptive Are you allergic to any of the following? AspirinPenicillinCodeineAcrylic MetalLatexSulfa DrugsLocal Anesthetics Do you use tobacco (including smokeless)? YesNo Do you or have you used controlled substances? YesNo Do you have, or have you had, any of the following? (Select the checkboxes for what you have had) AIDS/HIV PositiveExcessive ThirstMitral Valve Prolapse Alzheimer's DiseaseFainting Spells/DizzinessOsteoporosis AnaphylaxisFrequent CoughPain in Jaw Joints AnemiaFrequent HeadachesParathyroid Disease AnginaGenital HerpesPsychiatric Care Arthritis/GoutGlaucomaRadiation Treatments Artificial Hearth ValveHay FeverRecent Weight Loss Artificial JointHearing ImpairmentRenal Dialysis AsthmaHeart Attack/FailureRheumatic Fever Blood DiseaseHeart MurmurRheumatism Blood TransfusionHeart PacemakerScarlet Fever Breathing ProblemsHeart Trouble/DiseaseShingles Bruise EasilyHemophiliaSickle Cell Disease CancerHepatitis ASinus Trouble ChemotherapyHepatitis B or CSpina Bifida Chest PainsHerpesStomach/Intestinal Disease Cold Sores/Fever BlistersHigh Blood PressureStroke Congenital Heart DisorderHigh CholesterolSwelling of Limbs ConvulsionsHives or RashThyroid Disease Cortisone MedicineHypoglycemiaTonsillitis DiabetesIrregular HeartbeatTuberculosis Drug AddictionKidney ProblemsTumors or Growths Easily WindedLeukemiaUlcers EmphysemaLiver DiseaseVenereal Disease Epilepsy or SeizuresLow Blood PressureYellow Jaundice Excessive BleedingLung Disease

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