Medical History
If you are unsure of how to answer any questions, please leave blank. A team member will be reviewing with you at your appointment.
Name
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
Hospitalization for illness or injury
YES
NO
If yes, please explain
Medical allergies
Aspirin, ibuprofen, acetaminophen, codeine
Penicillin
Erythromycin
Tetracycline
Sulfa
Local anesthetic
Fluoride
Metals (nickle, gold, silver)
Latex
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Medical History
If you are unsure of how to answer any questions, please leave blank. A team member will be reviewing with you at your appointment.
Do you have or have you ever had:
Yes
No
Please explain
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
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
Diabetes
HbA1c
Stomach or duodenal ulcer
Digestive disorders (i.e. celiac disease, gastric reflux
Osteoporosis/osteopenia (i.e. taking Bisphosphonates
Arthritis
Autoimmune disease
Glaucoma
Contact lenses
Head or neck injuries
Epilepsy, convulsions
Neurologic disorders (ADD/ADHD, prion disease)
Viral infections and cold sores
Lumps or swelling in the mouth
Hives, skin rash, hay fever
STI / STD / HPV
Hepatitis
HIV / AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy, immunosuppressive medication
Emotional difficulties
Psychiatric treatment
Antidepressant medication
Alcohol / recreational drug use
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Medical History
If you are unsure of how to answer any questions, please leave blank. A team member will be reviewing with you at your appointment.
Are you:
Yes
No
Please explain
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
Prostate disorders
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)
Patient’s Signature
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Month
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Day
Year
Date
Doctor’s Signature
Date
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Month
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Day
Year
Date
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