Medical History

1
Which Polaris Dental Care location are you visiting?* This field is required.
Polaris Parkway - 2023 Polaris Parkway, Columbus OH 43240
Grandview Yard - 887 W 3rd Ave, Columbus, OH 43212
London Springfield - 8490 E National Rd, South Vienna OH 45369
Dublin - 420 Metro Place South, Suite B, Dublin OH 43017
2
Please fill in your legal name* This field is required.
First Name
Middle Name
Last Name
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
CurrentDate
Date
Month
Day
Year
5
Age
6
Gender (at birth)* This field is required.
Female
Male
Decline to answer
7
Do you take birth control medication* This field is required.
Yes
No
8
Are you currently/is there a chance you may be pregnant?* This field is required.
Yes
No
9
Are you nursing?* This field is required.
Yes
No
10
Have you ever been hospitalized?* This field is required.
Yes
No
11
What were you hospitalized for?* This field is required.
12
Do you have any known allergies at all?* This field is required.
Yes
No
13
Please mark anything you have a known allergy or negative reaction to:* This field is required.
NSAIDs (aspirin, ibuprofen)
Tylenol
Codeine
Penicillin or Amoxicillin
Tetracycline
Clindamycin
Sulpha
Reaction to Local Anesthetic
Metals (nickel, gold, silver, etc)
Latex
14
Please explain what happens when you take an NSAID
15
Please explain what happens when you take Tylenol
16
Please explain what happens when you take Codeine
17
Please explain what happens when you take Penicillin or Amoxicillin
18
Please explain what happens when you take Tetracycline
19
Please explain what happens when you take Clindamycin
20
Please explain what happens when you take Sulpha
21
Please explain which local anesthetic and the reaction
22
Please explain which metals and the reaction
23
Please explain what happens when you contact Latex
24
Please explain your reaction to "Other"
25
Please checkmark any heart issues you have ever had* This field is required.
Stent placed
History of infective Endocarditis
Artificial Heart Valve
Pacemaker or implantable defibrillator
History of a heart attack (even a "minor" one)
High Blood Pressure
Low Blood Pressure
Any other heart condition not listed here
I don't have any history of the above
26
Please list the date your stent, valve or pacemaker was placed and any other information about them
27
When did you have Endocarditis and what caused it?
28
Please list your heart attack history
29
How often do you check your blood pressure?
30
Please explain any other heart condition
31
Does you doctor require a pre-medication before dental treatment?* This field is required.
Yes
No
32
Have you been diagnosed with either Diabetes or Pre-Diabetes?* This field is required.
Yes
No
33
Do you take any medication for your diabetes?
Yes
No
34
Do you check you blood glucose daily?
Yes
No
35
What is your most recent HbA1C level and the date it was checked:
36
What is your most recent blood glucose level and the date it was checked:
37
Checkmark if you have any of the following:* This field is required.
Asthma
Tuberculosis
Emphesema
COPD
Snoring
Sleep Apnea
I don't have any history of the above
38
How often do you use your inhaler?
39
Do you use a CPAP?
40
Have you ever had/suffer some:* This field is required.
Seizures/Epilepsy
Stroke/TIA
Severe Headaches
I don't have any history of the above
41
What type of seizures do you have and how frequently? When was the most recent?
42
Please list your stroke history
43
Describe your headaches and frequency
44
Have you every been diagnosed with any form of cancer?* This field is required.
Yes
No
45
What type of cancer were you diagnosed with (and when)
46
What type of treatment did you undergo and when was it?
47
What is your current status regarding this cancer?
48
Have you ever had a joint replacement?* This field is required.
Yes
No
49
Please describe* This field is required.
50
Does you doctor require a pre-medication before dental treatment?* This field is required.
Yes
No
51
Have you every been diagnosed with a bone disorder (Osteoporosis or Osteopenia)* This field is required.
Yes
No
52
Have you ever (now or in the past) taken medication for Osteoporosis/Osteopenia?* This field is required.
Yes
No
53
What drugs did you take for this in the past? (specify if it was IV or Oral)
54
Do you have a history of* This field is required.
Hepatitis
AIDS/HIV
Venereal Disease
Herpes
any STDs
I don't have any history of the above
55
Please tell us the type of Hepatitis and your history of this
56
Please tell us your history HIV/AIDS
57
Please tell us your history of this
58
Please mark any conditions that apply* This field is required.
Anxiety/Depression
Anemia or other Bleeding disorder
Arthritis
Kidney Disease
Liver Disease
Thyroid issues
Hormonal Imbalance
Ulcers
Digestive Issues
Glaucoma
Head or Neck injuries
Prostate Disorder
Bladder issue
I don't have any history of the above
59
Please indicate dates you were diagnosed or had the issues you checked and current status:
Huge
Large
Normal
Small
Ok
Ok
60
Do you have any history at all of smoking?
YESNO
61
Please select the best answer
I quit smoking
I currently smoke
62
63
Congratulations on quitting!
64
Do you ever drink / Have you every drank alcohol?
YESNO
65
Please select the best answer
I quit drinking alcohol
I drink alcohol socially
I drink alcohol regularly
66
Congratulation on quitting!
67
How many drinks (can/bottle of beer, glass of wine, shot/mixed drink glass) in a week?
# of drinks/week
68
oldHave you taken any medication at all in the last 6 months (even Over the Counter)?
Yes
No
69
Have you taken any medication at all in the last 6 months (even Over the Counter)?
YESNO
70
Please enter your current medications. As you type the list will automatically fill in for common drugs.

If your drug is not listed you can still manually type it in.
71
Select a Medication
72
Add another?
Yes
No
73
Select a Medication
74
Add another?
Yes
No
75
Select a Medication
76
Add another?
Yes
No
77
Select a Medication
78
Add another?
Yes
No
79
Select Mediacation
Brand Name (Generic) - Typical Use
80
Add another?
Yes
No
81
Select a Medication
82
Add another?
Yes
No
83
Select a Medication
84
Add another?
Yes
No
85
Select a Medication
86
Add another?
Yes
No
87
Select a Medication
88
Add another?
Yes
No
89
Select a Medication
90
If you need to add more medications please bring your medication list to the office.
91
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