MEDICAL HISTORY
Patient Name:
*
First Name
Last Name
Birth Date:
*
Today's Date:
-
Month
-
Day
Year
Date
What is your estimate of your overall general health?
*
Excellent
Good
Fair
Poor
Have you ever been hospitalized for an illness or injury?
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Yes
No
If yes, please explain:
DO YOU HAVE OR HAVE YOU EVER HAD an allergic reaction to any of the following (select all that apply):
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
chlorhexidine (CHX)
metals (nickel, gold, silver, etc)
latex
nuts
fruit
Other
DO YOU HAVE OR HAVE YOU EVER HAD (select all that apply):
heart problems or cardiac stent within the last six months
history of infective endocarditis
artificial heart valve, repaired heart defect (PFO)
pacemaker or implantable defibrillator
orthopedic implant (joint replacement)
rheumatic or scarlet fever
high or low blood pressure
a stroke (taking blood thinners)
anemia or other blood disorder
prolonged bleeding due to a slight cut (INR > 3.5)
pneumonia, emphysema, shortness of breath, sarcoidosis
chronic ear infections, tuberculosis
asthma
breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
kidney disease
liver disease
jaundice
thyroid, parathyroid disease, or calcium deficiency
hormone deficiency
high cholesterol or taking statin drugs
diabetes
stomach or duodenal ulcer
digestive or eating disorders (celiac disease, gastric reflux)
osteoporosis/osteopenia (taking bisphosphonates)
arthritis
autoimmune disease (rheumatoid arthritis, lupus, scleroderma)
glaucoma
contact lenses
head or neck injuries
epilepsy/convulsions (seizures)
neurologic disorders (ADD/ADHD, prion disease)
viral infections and cold sores
any lumps or swelling in the mouth
hives, skin rash, hay fever
STI/STD/HPV
hepatitis
HIV/AIDS
tumor, abnormal growth
radiation therapy
chemotherapy, immunosuppressive medication
emotional difficulties
psychiatric treatment
antidepressant medication
alcohol/recreational drug use
ARE YOU (select all that apply):
presently being treated for any other illnesses
aware of a change in your health in the last 24 hours
taking medication for weight management
taking dietary supplements
often exhausted or fatigued
a smoker, smoked previously or use smokeless tobacco
considered a touchy/sensitive person
often unhappy or depressed
taking birth control pills
currently pregnant
diagnosed with a prostate disorder
Did you answer yes to any of the questions above?
*
Yes
No
If yes, please explain:
Describe any past or current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment (i.e. Botox/Collagen injections):
Please list all medications, supplements and/or vitamins taken within the last two years and provide purpose in the comment:
Signature of Patient, Parent or Guardian - Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid.
*
Date
-
Month
-
Day
Year
Date
Which of our offices should receive your forms?
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Portage office
Kalamazoo office
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