MEDICAL HISTORY FORM

MEDICAL HISTORY

Your Name (required)
Your Email (required)
Nickname
Age
Name of Physician/and their specialty
Most recent physical examination Purpose
What is your estimate of your general health?

DO YOU HAVE or HAVE YOU EVER HAD: yes or no

1. hospitalization for illness or injury yesno
2. an allergic reaction to:
- aspirin, ibuprofen, acetaminophen, codeine yesno
- penicillin yesno
- erythromycin yesno
- tetracycline yesno
- sulpha yesno
- local anesthetic yesno
- fluoride yesno
- metals (nickel, gold, silver) yesno
- latex yesno
- other yesno
3. heart problems, or cardiac stent within the last six months yesno
4. history of infective endocarditis yesno
5. artificial heart valve, repaired heart defect (PFO) yesno
6. pacemaker or implantable defibrillator yesno
7. artificial prosthesis (heart valve or joints) yesno
8. rheumatic or scarlet fever yesno
9. high or low blood pressure yesno
10.a stroke (taking blood thinners) yesno
11. anemia or other blood disorder yesno
12. prolonged bleeding due to a slight cut (INR > 3.5) yesno
13. emphysema, sarcoidosis yesno
14. tuberculosis yesno
15. asthma yesno
16. breathing or sleep problems (i.e. snoring, sinus) yesno
17. kidney disease yesno
18. liver disease yesno
19. jaundice yesno
20. thyroid, parathyroid disease, or calcium deficiency yesno
21. hormone deficiency yesno
22. high cholesterol or taking statin drugs yesno
23. diabetes (HbAlc =_______) yesno
24. stomach or duodenal ulcer yesno
25. digestive disorders (i.e. gastric reflux) yesno
26. osteoporosis/osteopenia (i.e. taking bisphosphonates) yesno
27. arthritis yesno
28. glaucoma yesno
29. contact lenses yesno
30. head or neck injuries yesno
31. epilepsy, convulsions (seizures) yesno
32. neurologic problems (attention deficit disorder) yesno
33. viral infections and cold sores yesno
34. any lumps or swelling in the mouth yesno
35. hives, skin rash, hay fever yesno
36. venereal disease yesno
37. hepatitis (type_) yesno
38. HIV /AIDS yesno
39. tumor; abnormal growth yesno
40. radiation therapy yesno
41. chemotherapy yesno
42. emotional problems yesno
43. psychiatric treatment yesno
44. antidepressant medication yesno
45. alcohol I drug dependency yesno

ARE YOU:

46. presently being treated for any other illness yesno
47. aware of a change in your general health yesno
48. taking medication for weight management (i.e. fen-phen) yesno
49. taking dietary supplementsyesno
50. often exhausted or fatigued yesno
51. subject to frequent headaches yesno
52. a smoker or smoked previously yesno
53. considered a touchy person yesno
54. often unhappy or depressed yesno
55. FEMALE -taking birth control pills yesno
56. FEMALE - pregnant yesno
57. MALE -prostate disorders yesno

Describe any current medical treatment, impending surgery, or other treat ment that may possibly affect your dental treatment.

List all medications, supplements, and or vitamins taken within the last two years
Drug Purpose

Ask for an additional sheet if you are taking more than 6 medications

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 ________