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Medical History

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Patient Info
- Name
  First Last
- Nickname
- Age
- 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:
- 1. hospitalization for illness or injury
  - Yes
  - No
- If yes, details
- 2. an allergic reaction to
  - penicillin
  - erythromycin
  - tetracycline
  - sulfa
  - local anesthetic
  - fluoride
  - metals (nickel, gold, silver)
  - latex
  - other
- 3. heart problems, or cardiac stent within the last six months
  - Yes
  - No
- 4. history of infective endocarditis
  - Yes
  - No
- 5. artificial heart valve, repaired heart defect (PFO)
  - Yes
  - No
- 6. pacemaker or implantable defibrillator
  - Yes
  - No
- 7. artificial prosthesis (heart valve or joints)
  - Yes
  - No
- 8. rheumatic or scarlet fever
  - Yes
  - No
- 9. high or low blood pressure
  - Yes
  - No
- 10. a stroke (taking blood thinners)
  - Yes
  - No
- 11. anemia or other blood disorder
  - Yes
  - No
- 12. prolonged bleeding due to a slight cut (INR > 3.5)
  - Yes
  - No
- 13. emphysema, sarcoidosis
  - Yes
  - No
- 14. tuberculosis
  - Yes
  - No
- 15. asthma
  - Yes
  - No
- 16. breathing or sleep problems (i.e. snoring, sinus)
  - Yes
  - No
- 17. kidney disease
  - Yes
  - No
- 18. liver disease
  - Yes
  - No
- 19. jaundice
  - Yes
  - No
- 20. thyroid, parathyroid disease, or calcium deficiency
  - Yes
  - No
- 21. hormone deficiency
  - Yes
  - No
- 22. high cholesterol or taking statin drugs
  - Yes
  - No
- 23. diabetes (HbA1c =_______)
  - Yes
  - No
- 24. stomach or duodenal ulcer
  - Yes
  - No
- 25. digestive disorders (i.e. gastric reflux)
  - Yes
  - No
- 26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
  - Yes
  - No
- 27. arthritis
  - Yes
  - No
- 28. glaucoma
  - Yes
  - No
- 29. contact lenses
  - Yes
  - No
- 30. head or neck injuries
  - Yes
  - No
- 31. epilepsy, convulsions (seizures)
  - Yes
  - No
- 32. neurologic problems (attention deficit disorder
  - Yes
  - No
- 33. viral infections and cold sores
  - Yes
  - No
- 34. any lumps or swelling in the mouth
  - Yes
  - No
- 35. hives, skin rash, hay fever
  - Yes
  - No
- 36. STI / STD
  - Yes
  - No
- 37. hepatitis (type ___)
  - Yes
  - No
- 38. HIV / AIDS
  - Yes
  - No
- 39. tumor, abnormal growth
  - Yes
  - No
- 40. radiation therapy
  - Yes
  - No
- 41. chemotherapy
  - Yes
  - No
- 42. emotional problems
  - Yes
  - No
- 43. psychiatric treatment
  - Yes
  - No
- 44. antidepressant medication
  - Yes
  - No
- 45. alcohol / street drug use
  - Yes
  - No
Are You
- 46. presently being treated for any other illness
  - Yes
  - No
- 47. aware of a change in your health (i.e. fever, new cough)
  - Yes
  - No
- 48. taking medication for weight management (i.e. fen-phen)
  - Yes
  - No
- 49. taking dietary supplements
  - Yes
  - No
- 50. often exhausted or fatigued
  - Yes
  - No
- 51. experiencing frequent headaches
  - Yes
  - No
- 52. a smoker, smoked previously or use smokeless tobacco
  - Yes
  - No
- 53. considered a touchy person
  - Yes
  - No
- 54. often unhappy or depressed
  - Yes
  - No
- 55. FEMALE - taking birth control pills
  - Yes
  - No
- 56. FEMALE - pregnant
  - Yes
  - No
- 57. MALE - prostate disorders
  - Yes
  - No
- 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
- Drug
- Purpose
- Drug
- Purpose
- Drug
- Purpose
- Drug
- Purpose
- Drug
- Purpose
- Drug
- Purpose
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

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