Medical History
Endodontic Associates in Framingham,P.C.
PATIENT NAME:
Are you in good health now?
Yes
No
If no, please explain:
Are you under the care of a physician for a current medical condition?
Yes
No
Condition:
Does your physician require you to take ANTIBIOTICS for your dental visits (PRE-MED)?
Yes
No
If yes, for what condition?
Are you allergic to LATEX (will the doctor’s latex gloves cause your skin to break out)?
Yes
No
Do you have any ALLERGIES (medications, food, environmental)?
Yes
No
If yes, please list:
Are you currently taking any MEDICATIONS?
Yes
No
If yes, please list:
Are you currently PREGNANT?
Yes
No
If YES, how many weeks?
Are you taking birth control?
Yes
No