K & K Dental Studio Medical History

Name: *

First Name Last Name

Nickname:

Age: *

Name of Physician:

First Name Last Name

Physician specialty:

Most recent physical examination:

Date

Purpose:

What is your estimate of your general health? *

Excellent Good Fair Poor

Are you allergic or do you have a bad reaction to any of the following? *

	Yes	No
Aspirin, ibuprofen, acetaminophen, codeine
Penicillin
Erythomycin
Tetracycline
Sulfa
Local anesthetic
Fluoride
Metals (nickel, gold, silver)
Latex
Nuts
Fruit

Other - if not on list above:

Do you have or have you ever had: *

	Yes	No
Hospitalization for illness or injury
Heart problems, or cardiac stent within the last six 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
Tuberculosis, measles, chicken pox
Asthma
Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
Kidney Disease
Liver Disease
Jaundice
Thyroid, parathyroid disease, or calcium deficiency
Hormone deficiency
High cholesterol or taking statin drugs
Stomach or duodenal ulcer
Digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)
Osteoporosis / osteopenia (i.e. taking bisphosphonates)
Arthritis
Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)
Glaucoma
Contact lenses
Head or 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
HIV / AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy, immunosuppressive medication
Emotional difficulties
Psychiatric treatment
Antidepressant medication
Alcohol / recreational drug use

Do you have diabetes? *

Yes No

If yes, what is your HbA1c

Do you have hepatitis? *

Yes No

If yes, what type

Are you: *

	Yes	No
Presently being treated for any other illness
Aware of a change in your health in the last 24 hours (i.e., 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
Considered 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. (ie., Botox, Collagen Injections)

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

Drug Purpose

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

Signature:

Use your mouse to sign by holding down the button continuously with your index finger and signing/moving the mouse in the signature box. Clear

Date: