ashevillesmiles.com - Medical History

Medical History
Patient Legal Name:
Preferred Name:
Date of Birth:

MonthDayYear
Date
Today’s Date:

MonthDayYear
Date
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the dentistry you receive. Thank you for taking the time to answer all of the following questions thoroughly and accurately.

By signing this form, I attest that to the best of my knowledge, the questions on this form have been answered accurately. I understand that providing inaccurate information can be dangerous to my health. It is my responsibility to inform the dental office of any changes to my medical history.

Please select Yes or No.
Are you under a physician’s care now?

YesNo
If yes, by whom:
Primary Care Doctor Name:
Last Seen:
Specialty Doctor’s Name:
Have you ever been hospitalized or had any surgeries?

YesNo
If yes, for what and when?
Have you ever had a serious head or neck injury?

YesNo
If yes...
Do you take or have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

YesNo
Do you take aspirin or any other type of blood thinners?

YesNo
Women:
Pregnant or Trying to get pregnant?

YesNo
Nursing?

YesNo
Taking oral contraceptives?

YesNo

Do you have, or have you had, any of the following?

	Yes	No
AIDS/HIV +
Alzheimer’s Disease
Anemia
Angina
Anxiety/Depression
Arthritis/Gout
Artificial Heart Valve
Artificial Joints
Asthma
Autoimmune Disease
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores
Congenital Heart Disorder
Convulsions
COPD
Diabetes
Drug Addiction
Easily Out of Breath?
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack
Heart Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Sleep Apnea
Spina Bifida
Stomach/Intestinal Diseases
Stroke
Swelling of the Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice

Do you have or have had any other medical issues not listed above?

Pharmacological History
Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicLatexMetalSulfa DrugsCephalosporinsClindamycinLocal AnestheticsOther
Current Medications:
Current Supplements:
Preferred Pharmacy Name:
Preferred Pharmacy Location:
Airway & Sleep Assessment
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

0= would never doze, 1= slight chance of dozing, 2= moderate chance of dozing, 3= high chance of dozing
Sitting and reading?

0

1

2

3

0 is would never doze, 3 is high chance of dozing
Watching TV?

0

1

2

3

0 is would never doze, 3 is high chance of dozing
Sitting inactive in a public place (ie: theater, meeting, etc)?

0

1

2

3

0 is would never doze, 3 is high chance of dozing
As a passenger in a car for an hour without a break?

0

1

2

3

0 is would never doze, 3 is high chance of dozing
Lying down to rest in the afternoon when circumstances permit?

0

1

2

3

0 is would never doze, 3 is high chance of dozing
Sitting and talk to someone?

0

1

2

3

0 is would never doze, 3 is high chance of dozing
In a car, while stopped for a few minutes in traffic?

0

1

2

3

0 is would never doze, 3 is high chance of dozing
Total Score:
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: