• Medical History

  • There are two ways to your answers to the following questions.

    1. Some questions have options of selecting "YES" or "NO". Answer all such questions by selecting yes or no.
    2. Some questions may have options for you to "Specify Details" if you have entered your response as a "YES" to the specific question.
  • Are you in good health?
  • Has there been any change in your general health in the past year?
  • Date of last physical exam
     - -
  • Are you currently under a physician's care for a particular problem.
  • Have you ever had any serious illness, operations or hospitalizations?

  • DO YOU OR HAVE YOU EVER HAD:

  • Rheumatic Fever or Rheumatic Disease?
  • Congenital Heart Disease?
  • Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker?)
  • Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing)
  • Seizures, Convulsion, Epilepsy, Fainting, Dizziness, Psychiatric Treatment or other Nervous Disorder?
  • Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you bruise easily?
  • Liver Disease (Jaundice, Hepatitis, cirrhosis)?
  • Kidney Disease, Bladder or prostate disease?
  • Diabetes, Type I, Type II, Diabetic complications like retinopathy, neuropathy, and trouble healing of tissues?
  • Thyroid Disease (Hyperthyroidism, Eurothroidism)?
  • Arthritis (Rheumatoid Arthritis, Osteoarthritis, Degenerative Arthritis)?
  • Stomach Problems (Ulcers, Reflux), Spleen or Colon related problems?
  • Do you have any artificial joints? Implant placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee)?
  • Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth?
  • Sinus or Nasal problems?
  • Have you been told that you are at risk of sleep apnea or have been diagnosed for sleep apnea?
  • Do you have or wear a CPAP machine for Sleep apnea?
  • Any disease, drug or transplant operation that has depressed your immune system?
  • Have you ever had any skin disease, eye related problems (Glaucoma, retinal defects, etc.) Throat or Neck related disease or surgery?

  • ARE YOU TAKING ANY OF THE FOLLOWING MEDICATIONS

  • Antibiotics?
  • Anticoagulants (Blood thinners)?
  • Aspirin or drugs such as Motrin, Aleve, Ibuprofen?
  • High Blood Pressure medications?
  • Steroids (Cortisone or similar steroids)?
  • Tranquilizers?
  • Any regular prescription medicine, pills or drugs?
  • Herbal or Holistic remedies, Vitamins or over the counter medications?

  • ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION TO?

  • Local Anesthetic (Novocaine, etc?)
  • Penicillin or other antibiotics?
  • Sedatives, Barbiturates (Like Valium or similar drugs)?
  • Aspirin or Ibuprofen?
  • Other allergies or reactions?
  • Do you smoke?
  • Do you chew tobacco?
  • Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect the care we provide you?
  • Have you had any serious problems associated with any previous dental treatment?
  • Do you have any other disease, condition or problem not listed above that you think the doctor should know about?
  • Do you wish to talk to the doctor privately about anything?

  • FEMALES ONLY

  • Are you pregnant or is there any chance you may be pregnant?

  • If you are using Oral Contraceptives, it is important that you understand that antibiotics (and other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.

  • Have you ever been told that you need to be pre-medicated prior to dental procedures?
  • Date:
     - -
  • Should be Empty: