Medical History Form
Patient Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Sex:
Emergency Contact
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
Do you have any of the following diseases or problems
Active Tuberculosis
Yes
No
Persistent cough greater than a 3 week duration
Yes
No
Cough that produces blood
Yes
No
Been exposed to anyone with tuberculosis
Yes
No
Medical History
Are you now under the care of a physician?
Yes
No
Physician Name
Phone
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you in good health?
Yes
No
Has there been any change in your general health within the past year?
Yes
No
If yes, what condition is being treated?
Date of last physical exam
-
Month
-
Day
Year
Date
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Yes
No
If yes, what was the illness or problem?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?
Yes
No
If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements
Do you wear contact lenses?
Yes
No
Joint Replacement. Have you had any orthopedic total joint (hip, knee, elbow, finger) replacement?
Yes
No
Date
-
Month
-
Day
Year
Date
If yes, have you had any complications?
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax0) or risedronate (ActonelS) for osteoporosis or Paget's disease?
Yes
No
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous biphosphonates (Aredia® or ZometaCD) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?
Yes
No
Date Treatment began
-
Month
-
Day
Year
Date
Do you use controlled substances (drugs)?
Yes
No
Do you use tobacco (smoking, snuff, chew, bidis)?
Yes
No
If so, are you interested in stopping? VERY! SOMEWHAT / NOT INTERESTED
Do you drink alcoholic beverages?
Yes
No
If yes, how much alcohol did you drink in the last 24 hours?
If yes, how much do you typically drink in a week?
WOMEN ONLY. Are you:
Pregnant
Yes
No
Number of weeks
Taking birth control pills or hormonal replacement?
Yes
No
Nursing?
Yes
No
Allergies
Are you allergic to or have you had any reaction to
Local anesthetics
Yes
No
Aspirin
Yes
No
Penicillin or other antibiotics
Yes
No
Barbiturates, sedatives, or sleeping pills
Yes
No
Sulfa drugs
Yes
No
Codeine or other narcotics
Yes
No
Metals
Yes
No
Latex (rubber)
Yes
No
Iodine
Yes
No
Hay fever/seasonal
Yes
No
Animals
Yes
No
Food
Yes
No
Other
Yes
No
If Other, please specify:
Congenital Heart Disease (CHD)
Please indicate if you have had or not had any of the following:
Artificial (prosthetic) heart valve
Yes
No
Previous infective endocarditis
Yes
No
Damaged valves in transplanted heart
Yes
No
Congenital heart disease (CHD)
Yes
No
Unrepaired, cyanotic CHD
Yes
No
Repaired (completely) in the last 6 months
Yes
No
Repaired CHD with residual defects
Yes
No
Other Diseases and Conditions
Please indicate if you have had or not had any of the following:
Cardiovascular disease
Yes
No
Angina
Yes
No
Arteriosclerosis
Yes
No
Congestive heart failure
Yes
No
Damaged heart valves
Yes
No
Heart attack
Yes
No
Heart murmur
Yes
No
Low blood pressure
Yes
No
High blood pressure
Yes
No
Other congenital heart defects
Yes
No
Mitral valve prolapse
Yes
No
Pacemaker
Yes
No
Rheumatic fever
Yes
No
Rheumatic heart disease
Yes
No
Abnormal bleeding
Yes
No
Anemia
Yes
No
Blood transfusion
Yes
No
If yes, date
-
Month
-
Day
Year
Date
Hemophilia
Yes
No
AIDS or HIV
Yes
No
Arthritis
Yes
No
Autoimmune disease
Yes
No
Rheumatoid arthritis
Yes
No
Systemic lupus erythematosus
Yes
No
Asthma
Yes
No
Bronchitis
Yes
No
Emphysema
Yes
No
Sinus trouble
Yes
No
Tuberculosis
Yes
No
Cancer/Chemotherapy/Radiation Treatment
Yes
No
Chest pain upon exertion
Yes
No
Chronic pain
Yes
No
Diabetes Type I or II
Yes
No
Eating disorder
Yes
No
Malnutrition
Yes
No
Gastrointestinal disease
Yes
No
G.E. Reflux/persistent heartburn
Yes
No
Thyroid problems
Yes
No
Stroke
Yes
No
Glaucoma
Yes
No
Hepatitis, jaundice or liver disease
Yes
No
Epilepsy
Yes
No
Fainting spells or seizures
Yes
No
Neurological disorders
Yes
No
If yes, please specify
Sleep disorder
Yes
No
Mental health disorders
Yes
No
Specify
Mental health disorders
Yes
No
Recurrent infections
Yes
No
Type of infection
Kidney problems
Yes
No
Night sweats
Yes
No
Osteoporosis
Yes
No
Persistent swollen glands in neck
Yes
No
Severe headaches/migraines
Yes
No
Severe or rapid weight loss
Yes
No
Sexually transmitted disease
Yes
No
Excessive urination
Yes
No
Premedication
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Yes
No
Name of physician or dentist making recommendation (include phone number)
Do you have any disease, condition, or problem not listed above that you think I should know about?
Yes
No
Please explain
Signature of Patient/Legal Guardian
Submit
Should be Empty: