Medical History
Patient Name
*
First Name
Middle Name
Last Name
Nickname
Age
*
Name of Physician/and their specialty
*
Date of most recent physical examination
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purpose of most recent physical examination
*
What is your estimate of your general health?
*
Excellent
Good
Fair
Poor
Do you have or have you ever had an allergic or bad reaction to any of the following:
*
Rows
Yes
No
Aspirin, Ibuprofen, Acetaminophen, Codeine
Penicillin
Erythromycin
Tetracycline
Sulfa
Local Anesthetic
Fluoride
Chlorhexidine (CHX)
Metals (nickle, gold, silver, other metals)
Latex
Nuts
Fruit
Any other allergic or bad reaction items that we should know about?
Do You Have or Have You Ever Had:
*
Rows
Yes
No
Hospitalization for illness or injury
Heart problems or cardiac stent within the last 6 months
History of infective endocarditis
Artificial heart valve, repaired heart defect (PFO)
Pacemaker or implantable defibrillator
Orthopedic implant (joint replacement)
Rheumatic or scarlet fever
High or low blood pressure
A stroke (taking blood thinners)
Anemia or other blood disorder
Prolonged bleeding due to a slight cut (INR >3.5)
Pneumonia, emphysema, shortness of breath, sarcoidosis
Chronic ear infections, tuberculosis, measles, chicken pox
Asthma
Breathing or sleep problems (e.g. sleep apnea, snoring, sinus)
Kidney disease
Liver disease
Jaundice
Thyroid, parathyroid disease, or calcium deficiency
Hormone deficiency
High cholesterol or taking statin drugs
Diabetes
Stomach or duodenal ulcer
Digestive or eating disorders
Osteoporosis/osteopenia (e.g. taking bisphosphonates)
Arthritis
Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
Glaucoma
Contact lenses
Head and neck injuries
Epilepsy, convulsions (seizures)
Neurologic disorders (ADD/ADHD, prion disease)
Viral infections and cold sores
Any lumps or swelling in the mouth
Hives, skin rash, hay fever
STI/STD/HPV
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
HIV/AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy, immunosuppressive medication
Emotional difficulties
Psychiatric Treatment
Antidepressant Medication
Alcohol/ recreational drug use
Are You:
*
Rows
Yes
No
Presently being treated for any other illness
Aware of a change in your health in the last 24 hours (e.g. fever, chills, new cough, or diarrhea)
Taking medication for weight management
Taking dietary supplements
Often exhausted or fatigued
Experiencing frequent headaches
A smoker, smoked previously or use smokeless tobacco
Consider a touchy/sensitive person
Often unhappy or depressed
Taking birth control pills
Currently pregnant
Diagnosed with a prostate disorder
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/or vitamins taken within the last two years
Rows
Drug
Purpose
1.
2.
3.
4.
5.
6.
7.
8.
Patient's Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: