• Patient Name * 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 / NO
  • 1. hospitalization for illness or injury
         *               

  • 2. an allergic or bad reaction to any of the following: 
       *      

  • 3. heart problems, or cardiac stent within the last six months  
       *               

  • 4. history of infective endocarditis
       *               

  • 5. artificial heart valve, repaired heart defect (PFO)
       *               

  • 6. pacemaker or implantable defibrillator
       *               

  • 7. orthopedic or soft tissue implant (e.g joint replacement, breast implant)
       *               

  • 8. heart murmur, 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 (or INR > 3.5)
       *               

  • 13. pneumonia, emphysema, shortness of breath, sarcoidosis
       *               

  • 14. chronic ear infections, tuberculosis, measles, chicken pox
       *               

  • 15. breathing problems (e.g. asthma, stuffy nose, sinus congestion)
       *               

  • 16. sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
       *               

  • 17. kidney disease
       *               

  • 18. liver disease or jaundice
       *               

  • 19. vertigo (e.g. ”the room is spinning”)
       *               

  • 20. thyroid, parathyroid disease, or calcium deficiency
       *               

  • 21. hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)
       *               

  • 22. high cholesterol or taking statin drugs
       *               

  • 23. diabetes
       *               

  • 24. stomach or duodenal ulcer
       *               

  • 25. digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
       *               

  • 26. osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)
       *               

  • 27. arthritis or gout
       *               

  • 28. autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
       *               

  • 29. glaucoma
       *               

  • 30. contact lenses
       *               

  • 31. head or neck injuries
       *               

  • 32. epilepsy, convulsions (seizures)
       *               

  • 33. neurologic disorders (e.g. Alzheimer’s disease, dementia, 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
       *               

  • 39. HIV/AIDS
       *               

  • 40. tumor, abnormal growth
       *               

  • 41. radiation therapy
       *               

  • 42. chemotherapy, immunosuppressive medication
       *               

  • 43. emotional difficulties
       *               

  • 44. psychiatric treatment or antidepressant medication
       *               

  • 45. concentration problems or ADD/ADHD
       *               

  • 46. alcohol/recreational drug use
       *               

  • ARE YOU:

  • 47. presently being treated for any other illness
       *               

  • 48. aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
       *               

  • 49. taking medication for weight management
       *               

  • 50. taking dietary supplements, vitamins, and/or probiotics
       *               

  • 51. often exhausted or fatigued
       *               

  • 52. experiencing frequent headaches or chronic pain
       *               

  • 53. a smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis)
       *               

  • 54. considered a touchy/sensitive person
       *               

  • 55. often unhappy or depressed
       *               

  • 56. taking birth control pills
       *               

  • 57. currently pregnant
       *               

  • 58. 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, vitamins, and/or probiotics taken within the last two years.

  • PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

  • Patient’s Signature   *   

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