Medical History

Patient Name
Name of Physician/and their specialty
Most recent physical examination
What is your estimate of your general health?

Excellent Good Fair Poor
DO YOU HAVE OR HAVE YOU EVER HAD:
hospitalization for illness or injury

yes no
Reason for hospitalization
an allergic reaction to:

aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride metals (nickel, gold, silver) latex
heart problems, or cardiac stent within the last six months

yes no
history of infective endocarditis

yes no
artificial heart valve, repaired heart defect (PFO)

yes no
pacemaker or implantable defibrillator

yes no
orthopedic implant (joint replacement)

yes no
rheumatic or scarlet fever

yes no
high or low blood pressure

yes no
a stroke (taking blood thinners)

yes no
anemia or other blood disorder

yes no
prolonged bleeding due to a slight cut (INR > 3.5)

yes no
emphysema, shortness of breath, sarcoidosis

yes no
tuberculosis, measles, chicken pox

yes no
asthma

yes no
breathing or sleep problems (ie sleep apnea, snoring, sinus)

yes no
kidney disease

yes no
liver disease

yes no
jaundice

yes no
thyroid, parathyroid disease, or calcium deficiency

yes no
hormone deficiency

yes no
high cholesterol or taking statin drugs

yes no
diabetes HbA1c

yes no
stomach or duodenal ulcer

yes no
digestive disorders (i.e. celiac disease, gastric reflux)

yes no
osteoporosis/osteopenia (i.e. taking bisphosphonates)

yes no
arthritis

yes no
autoimmune disease

yes no
glaucoma

yes no
contact lenses

yes no
head or neck injuries

yes no
epilepsy, convulsions (seizures)

yes no
neurologic disorders (ADD/ADHD, prion disease)

yes no
viral infections and cold sores

yes no
any lumps or swelling in the mouth

yes no
hives, skin rash, hay fever

yes no
STI / STD / HPV

yes no
hepatitis

yes no
if yes - hepatitis type
HIV / AIDS

yes no
tumor, abnormal growth

yes no
radiation therapy

yes no
chemotherapy, immunosuppressive medication

yes no
emotional difficulties

yes no
psychiatric treatment

yes no
antidepressant medication

yes no
alcohol / recreational drug use

yes no
DO YOU HAVE OR HAVE YOU EVER HAD:
presently being treated for any other illness

yes no
aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)

yes no
taking medication for weight management

yes no
taking dietary supplements

yes no
often exhausted or fatigued

yes no
experiencing frequent headaches

yes no
a smoker, smoked previously or use smokeless tobacco

yes no
considered a touchy / sensitive person

yes no
often unhappy or depressed

yes no
FEMALE - taking birth control pills

yes no
FEMALE - pregnant

yes no
MALE - prostate disorders

yes no
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (ie Botox, Collagen Injections)
List all medications, supplements and/or vitamins taken within the last two years.
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Patient’s Signature

Clear
Date

Month Day Year
Date
Should be Empty:

DO YOU HAVE OR HAVE YOU EVER HAD:

DO YOU HAVE OR HAVE YOU EVER HAD: