Medical History Form
Patient Name
*
First Name
Last Name
Nickname
Age
*
Gender
*
Please Select
Male
Female
Pharmacy
Name of Physician/and their specialty
Most recent physical examination
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Purpose
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What is your estimate of your general health?
*
Excellent
Good
Fair
Poor
Describe
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Do you have or have you ever had
Hospitalization for illness or injury
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Yes
No
Describe
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An allergic or bad reaction to any of the following
Aspirin, ibuprofen, acetaminophen, codeine
Penicillin
Erythromycin
Tetracycline
Sulfa
Local anesthetic
Fluoride
Lodine
Chlorhexidine (CHX)
Metals (nickel, gold, silver)
Latex
Nuts
Fruit
Milk
Red dye
Other
Please type other allergic or bad reactions here.
Heart problems, or cardiac stent within the last six months
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Yes
No
Describe
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History of infective endocarditis
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Yes
No
Describe
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Artificial heart valve, repaired heart defect (PFO)
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Yes
No
Describe
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Pacemaker or implantable defibrillator
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Yes
No
Describe
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Orthopedic or soft tissue implant (e.g joint replacement, breast implant)
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Yes
No
Describe
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Heart murmur, rheumatic or scarlet fever
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Yes
No
Describe
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High or low blood pressure
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Yes
No
Describe
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A stroke (taking blood thinners)
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Yes
No
Describe
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Anemia or other blood disorder
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Yes
No
Describe
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Prolonged bleeding due to a slight cut (or INR> 3.5)
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Yes
No
Describe
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Pneumonia, emphysema, shortness of breath, sarcoidosis
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Yes
No
Describe
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Chronic ear infections, tuberculosis, measles, chicken pox
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Yes
No
Describe
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Breathing problems (e.g. asthma, stuffy nose, Sinus congestion)
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Yes
No
Describe
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Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
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Yes
No
Describe
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Kidney Disease
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Yes
No
Describe
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Liver disease or jaundice
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Yes
No
Describe
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Vertigo (e.g. The room is spinning)
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Yes
No
Describe
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Thyroid, parathyroid disease, or calcium deficiency.
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Yes
No
Describe
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Hormone deficiency or imbalance (e.g. Polycystic ovarian syndrome)
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Yes
No
Describe
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High cholesterol or taking statin drugs
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Yes
No
Describe
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Diabetes
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Yes
No
Hba1c
*
Stomach or duodenal ulcer
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Yes
No
Describe
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Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
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Yes
No
Describe
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Osteoporosis/osteopenia or ever taken anti-resorptivemedications (e.g. bisphosphonates )
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Yes
No
Describe
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Arthritis or gout
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Yes
No
Describe
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Autoimmune Disease (e.g. rheumatoid arthritis, lupus, scleroderma)
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Yes
No
Describe
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Glaucoma
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Yes
No
Describe
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Contact Lenses
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Yes
No
Describe
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Head or neck injuries
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Yes
No
Describe
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Epilepsy, convulsions (seizures)
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Yes
No
Describe
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Neurologic disorders (e.g. Alzheimer’s disease, dementia, prion disease)
*
Yes
No
Describe
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Viral infections and cold sores
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Yes
No
Describe
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Any lumps or swelling in the mouth
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Yes
No
Describe
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Hives, skin rash, hay fever
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Yes
No
Describe
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STI/ STD/ HPV
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Yes
No
Describe
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Hepatitis
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Yes
No
Type
*
HIV/AIDS
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Yes
No
Describe
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Tumor, abnormal growth
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Yes
No
Describe
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Radiation therapy
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Yes
No
Describe
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Chemotherapy, immunosuppressive medication
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Yes
No
Describe
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Emotional difficulties
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Yes
No
Describe
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Psychiatric treatment or antidepressant medication
*
Yes
No
Describe
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Concentration problems or ADD/ADHD
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Yes
No
Describe
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Alcohol/recreational drug use
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Yes
No
Describe
*
ARE YOU
Presently being treated for any other illness
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Yes
No
Describe
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Aware of a change in your health in the last 24 hours (e.g. Fever, chills, new cough, or diarrhea)
*
Yes
No
Describe
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Taking medication for weight management
*
Yes
No
Describe
*
Taking dietary supplements, vitamins, and/or probiotics
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Yes
No
Describe
*
Often exhausted or fatigued
*
Yes
No
Describe
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Experiencing frequent headaches or chronic pain
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Yes
No
Describe
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A smoker, smoked previously or other (smokeless tobacco,vaping, e-cigarettes, and cannabis)
*
Yes
No
Describe
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Considered a touchy/sensitive person
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Yes
No
Describe
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Often unhappy or depressed
*
Yes
No
Describe
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Taking birth control pills
Yes
No
Describe
*
Currently Pregnant
*
Yes
No
Describe
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Diagnosed with a prostate disorder
*
Yes
No
Describe
*
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections).
List all medications, supplements, vitamins, and/or probiotics taken within the last two years.
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATION YOU MAYBE TAKING.
Patient’s signature
*
Name
*
First Name
Last Name
Date
*
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