Patient Name Patient Name* Nickname Nickname* Age   Age* Name of Physician/and their specialty   Name of Physician/and their specialty*  Most recent physical examination Most recent physical examination* Purpose   Purpose* .

What is your estimate of your general health?   Excellent    Good    Fair    Poor*      

1. hospitalization for illness or injury
  Yes   No*               

2. an allergic or bad reaction to any of the following: 
Yes    No*      

3. heart problems, or cardiac stent within the last six months  
Yes   No*               

4. history of infective endocarditis
Yes   No*               

5. artificial heart valve, repaired heart defect (PFO)
Yes   No*               

6. pacemaker or implantable defibrillator
Yes   No*               

7. orthopedic or soft tissue implant (e.g joint replacement, breast implant)
Yes   No*               

8. heart murmur, rheumatic or scarlet fever
Yes   No*               

9. high or low blood pressure
Yes   No*               

10. a stroke (taking blood thinners)
Yes   No*               

11. anemia or other blood disorder
Yes   No*               

12. prolonged bleeding due to a slight cut (or INR > 3.5)
Yes   No*               

13. pneumonia, emphysema, shortness of breath, sarcoidosis
Yes   No*               

14. chronic ear infections, tuberculosis, measles, chicken pox
Yes   No*               

15. breathing problems (e.g. asthma, stuffy nose, sinus congestion)
Yes   No*               

16. sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
Yes   No*               

17. kidney disease
Yes   No*               

18. liver disease or jaundice
Yes   No*               

19. vertigo (e.g. ”the room is spinning”)
Yes   No*               

20. thyroid, parathyroid disease, or calcium deficiency
Yes   No*               

21. hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)
Yes   No*               

22. high cholesterol or taking statin drugs
Yes   No*               

23. diabetes
Yes   No*               

24. stomach or duodenal ulcer
Yes   No*               

25. digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
Yes   No*               

26. osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)
Yes   No*               

27. arthritis or gout
Yes   No*               

28. autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
Yes   No*               

29. glaucoma
Yes   No*               

30. contact lenses
Yes   No*               

31. head or neck injuries
Yes   No*               

32. epilepsy, convulsions (seizures)
Yes   No*               

33. neurologic disorders (e.g. Alzheimer’s disease, dementia, prion disease)
Yes   No*               

34. viral infections and cold sores
Yes   No*               

35. any lumps or swelling in the mouth
Yes   No*               

36. hives, skin rash, hay fever
Yes   No*               

37. STI/STD/HPV Yes   No*               

38. hepatitis
Yes   No*               

39. HIV/AIDS
Yes   No*               

40. tumor, abnormal growth
Yes   No*               

41. radiation therapy
Yes   No*               

42. chemotherapy, immunosuppressive medication
Yes   No*               

43. emotional difficulties
Yes   No*               

44. psychiatric treatment or antidepressant medication
Yes   No*               

45. concentration problems or ADD/ADHD
Yes   No*               

46. alcohol/recreational drug use
Yes   No*               

47. presently being treated for any other illness
Yes   No*               

48. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
Yes   No*               

49. taking medication for weight management
Yes   No*               

50. taking dietary supplements, vitamins, and/or probiotics
Yes   No*               

51. often exhausted or fatigued
Yes   No*               

52. experiencing frequent headaches or chronic pain
Yes   No*               

53. a smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis)
Yes   No*               

54. considered a touchy/sensitive person
Yes   No*               

55. often unhappy or depressed
Yes   No*               

56. taking birth control pills
Yes   No*               

57. currently pregnant
Yes   No*               

58. diagnosed with a prostate disorder
Yes   No*               

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) blanks*

Patient’s Signature   Signature*