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MEDICAL HISTORY
Patient Name
Preferred Name
Age
Date
Name of Physician/and their specialty
Most recent physical examination
Purpose
What is your estimate of your general health?
Excellent
Good
Fair
Poor
DO YOU HAVE or HAVE YOU EVER HAD
YES
NO
1. Hospitalization for illness or injury
2. An allergic reaction to
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
chlorhexidine (CHX)
metals (nickel, gold, silver,
)
latex
nuts
fruit
other
3. Heart problems/cardiac stent last 6 months
4. History of infective endocarditis
5. Artificial heart valve, repaired heart defect (PFO)
6. Pacemaker or implantable defibrillator
7. Orthopedic implant (joint replacement)
8. Rheumatic or scarlet fever
9. High or low blood pressure
10. A stroke (taking blood thinners)
11. Anemia or other blood disorder
12. Prolonged bleeding due to a slight cut (INR>3.5)
13. Pneumonia, emphysema, shortness of breath, sarcoidosis
14. Chronic ear infections, tuberculosis, measles, chicken pox
15. Asthma
16. Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
17. Kidney disease
18. Liver disease
19. Jaundice
20. Thyroid, parathyroid disease, or calcium deficiency
21. Hormone deficiency
22. High cholesterol or taking statin drugs
23. Diabetes (HbA1c =
)
DO YOU HAVE or HAVE YOU EVER HAD
YES
NO
24. Stomach or duodenal ulcer
25. Digestive or eating disorders (e.g. celiac disease, gastric reflux, bullimia, anorexia)
26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. Arthritis
28. Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)
29. Glaucoma
30. Contact lenses
31. Head or neck injuries
32. Epilepsy, convulsions (seizures)
33. Neurologic disorders (ADD/ADHD, prion disease)
34. Viral infections and cold sores
35. Any lumps or swelling in the mouth
36. Hives, skin rash, hay fever
37. STI/STD/HPV
38. Hepatitis (type
)
39. HIV/AIDS
40. Tumor, abnormal growth
41. Radiation therapy
42. Chemotherapy, immunosuppressive medication
43. Emotional difficulties
44. Psychiatric treatment
45. Antidepressant medication
46. Alcohol/recreational drug use
ARE YOU:
47. Presently being treated for other illness
48. Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
49. Taking medication for weight management
50. Taking dietary supplements
51. Often exhausted or fatigued
52. Experiencing frequent headaches
53. A smoker, smoked previously or use smokeless tobacco
54. Considered a touchy/sensitive person
55. Often unhappy or depressed
56. Taking birth control pills
57. Currently pregnant
58. Diagnosed with prostate disorders
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)
List all medications, supplements, and other vitamins taken within the last two years:
Drug
Purpose
Drug
Purpose
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Patient's Signature
Date
Doctor's Signature
Date
Please fill out completely as possible. When submitting online, please type Patient's Name in the signature field above. Submission of this form is same as signing this form.
