MEDICAL HISTORY
Patient Name
*
First Name
Last Name
Nickname
Age
Name of Physician / and their specialty
Most recent physical examination
Purpose
What is your estimate of your general health?
*
Excellent
Good
Fair
Poor
Describe
*
DO YOU HAVE or HAVE YOU EVER HAD
(Please answer "Yes" or "No" to the following)
Hospitalization for illness or injury
Yes
No
Describe
*
An allergic reaction to
Aspirin, ibuprofen, acetaminophen, codeine
Penicillin
Erythromycin
Tetracycline
Sulfa
Local anesthetic
Fluoride
Metals (nickel, gold, silver)
Latex
Other
Please List
Heart problems, or cardiac stent within the last six months
*
Yes
No
Describe
*
History of infective endocarditis
*
Yes
No
Describe
*
Artificial heart valve, repaired heart defect (PFO)
*
Yes
No
Describe
*
Pacemaker or implantable defibrillator
*
Yes
No
Describe
*
Artificial prosthesis (heart valve or joints)
*
Yes
No
Describe
*
Rheumatic or scarlet fever
*
Yes
No
Describe
*
High or low blood pressure
*
Yes
No
Describe
*
A stroke (taking blood thinners)
*
Yes
No
Describe
*
Anemia or other blood disorder
*
Yes
No
Describe
*
Prolonged bleeding due to a slight cut (or INR> 3.5)
*
Yes
No
Describe
*
Emphysema, sarcoidosis
*
Yes
No
Describe
*
Tuberculosis
*
Yes
No
Describe
*
Asthma
*
Yes
No
Describe
*
Breathing or sleep problems (i.e. snoring, sinus)
*
Yes
No
Describe
*
Kidney disease
*
Yes
No
Describe
*
Liver disease
*
Yes
No
Describe
*
Jaundice
*
Yes
No
Describe
*
Thyroid, parathyroid disease, or calcium deficiency
*
Yes
No
Describe
*
Hormone deficiency
*
Yes
No
Describe
*
High cholesterol or taking statin drugs
*
Yes
No
Describe
*
Diabetes (HbA1c)
*
Yes
No
Describe
*
Stomach or duodenal ulcer
*
Yes
No
Describe
*
Digestive disorders (i.e. gastric reflux)
*
Yes
No
Describe
*
Osteoporosis/osteopenia (i.e. taking bisphosphonates)
*
Yes
No
Describe
*
Arthritis
*
Yes
No
Describe
*
Glaucoma
*
Yes
No
Describe
*
Contact lenses
*
Yes
No
Describe
*
Head or neck injuries
*
Yes
No
Describe
*
Epilepsy, convulsions (seizures)
*
Yes
No
Describe
*
Neurologic problems (attention deficit disorder)
*
Yes
No
Describe
*
Viral infections and cold sores
*
Yes
No
Describe
*
Any lumps or swelling in the mouth
*
Yes
No
Describe
*
Hives, skin rash, hay fever
*
Yes
No
Describe
*
STI / STD
*
Yes
No
Describe
*
Hepatitis
*
Yes
No
Type
*
HIV / AIDS
*
Yes
No
Describe
*
Tumor, abnormal growth
*
Yes
No
Describe
*
Radiation therapy
*
Yes
No
Describe
*
Chemotherapy
*
Yes
No
Describe
*
Emotional problems
*
Yes
No
Describe
*
Psychiatric treatment
*
Yes
No
Describe
*
Antidepressant medication
*
Yes
No
Describe
*
Alcohol / street drug use
*
Yes
No
Describe
*
ARE YOU:
Presently being treated for any other illness
*
Yes
No
Describe
*
Aware of a change in your health (i.e. fever, new cough)
*
Yes
No
Describe
*
Taking medication for weight management (i.e. fen-phen)
*
Yes
No
Describe
*
Taking dietary supplements
*
Yes
No
Describe
*
Often exhausted or fatigued
*
Yes
No
Describe
*
Experiencing frequent headaches
*
Yes
No
Describe
*
A smoker, smoked previously or use smokeless tobacco
*
Yes
No
Describe
*
Considered a touchy person
*
Yes
No
Describe
*
Often unhappy or depressed
*
Yes
No
Describe
*
FEMALE - taking birth control pills
Yes
No
Describe
*
FEMALE - pregnant
*
Yes
No
Describe
*
MALE - prostate disorders
*
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)
Have you taken medications, supplements, vitamins, and / or probiotics in the last two years?
*
Yes
No
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 MEDICATIONS YOU MAY BE TAKING.
Patient’s signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: