Medical History
Name
Preferred Name
How would you rate your overall health?
Excellent
Good
Fair
Poor
Have you recently been hospitalized?
Allergy or adverse reaction to any of the following…
None
Aspirin, ibuprofen, acetaminophen
Tetracycline
Fluoride
Penicillin
Metals (nickel, gold, silver______)
Sulfa drugs
Fruit
Erythromycin
Iodine
Local anesthetic
Latex
Chlorhexidine
Codeine
Nuts
Seasonal allergies
Shellfish
Other
Additional Metal Allergy Information
Have you had any of the following?
Please mark either Yes or No
Heart problems in the last 6 months
No
Yes, list date:
Diagnosed with congestive heart failure
No
Yes, list date:
Artificial heart valve
No
Yes, list date:
History of endocarditis
No
Yes, list date:
Pacemaker/Implantable defibrillator
No
Yes, list date:
Artificial Joint
No
Yes, list date:
Rheumatic or Scarlet Fever
No
Yes, list date:
High or low blood pressure
No
Yes, list date:
Stroke
No
Yes, list date:
Heart attack
No
Yes, list date:
Anemia or other blood disorders
Yes
No
Prolonged bleeding
Yes
No
Taking blood thinners (i.e. Coumadin)
Yes
No
Pneumonia
Yes
No
Emphysema
Yes
No
Shortness of breath
Yes
No
Sacoidosis
Yes
No
Chronic ear infections
Yes
No
Tuberculosis
Yes
No
Measles
Yes
No
Chicken Pox
Yes
No
Asthma
Yes
No
Sleep Problems (apnea, snoring, sinus issues)
Yes
No
Do you wear a CPAP or sleep appliance
Yes
No
Kidney disease
Yes
No
Liver disease
Yes
No
Jaundice
Yes
No
Thyroid, parathyroid, calcium deficiency
Yes
No
Hormone deficiency
Yes
No
Diabetes
No
Yes, last A1c:
Stomach ulcers
Yes
No
Digestive or eating disorders (GERD, anorexia, bulimia, celiac)
Yes
No
Osteoporosis /Osteopenia (taking bisphosphonates)
Yes
No
Arthritis
Yes
No
Autoimmune disease
Yes
No
Glaucoma
Yes
No
Contact lenses
Yes
No
Head or neck injjuries
Yes
No
Epilepsy, convulsions (seizures)
Yes
No
Neurological disorders (ADD/ADHD, prion disease)
Yes
No
Viral infections
Yes
No
Lumps or swelling in the mouth
Yes
No
Hives, skin rash, hay fever
Yes
No
STI / STD / HPV
Yes
No
Hepatitis
Yes
No
Note type
Hepatitis A, B, C
HIV / AIDS
Yes
No
Tumors / Cancers
Yes
No
Radiation therapy
Yes
No
Chemotherapy, Immunosuppressive medication
Yes
No
Emotional difficulties
Yes
No
Dizziness / fainting spells
Yes
No
Psychiatric treatment
Yes
No
Antidepressant medications
Yes
No
Excessive alcohol/drug use
Yes
No
Women
Currently pregnant
Yes
No
Nursing
Yes
No
Taking birth control pills
Yes
No
Men
Diagnosed with prostate disorder
Yes
No
Are you...?
Please mark either Yes or No
Being treated for any other illness
Yes
No
Aware of changes to your health in the last 24hrs
Yes
No
Taking dietary supplements, or weight management medications
Yes
No
Often exhausted or fatigued
Yes
No
Experiencing frequent headaches
Yes
No
A smoker, previous smoker, or use smokeless tobacco
Yes
No
Considered a touch sensitive person
Yes
No
Often unhappy or depressed
Yes
No
Any other conditions or alerts to clarify?
*
Are you taking antibiotic premedication for your dental visits, if yes, please explain?
*
Name of current physician
*
Name and location of preferred pharmacy
*
Describe any medical treatment, impending surgeries, genetic/development delays, or other things that may affect your dental treatment today
*
*
By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this form, and have responded accordingly. There are no other medical conditions, medications or allergies that have not been listed. I am aware that I must notify the practice of any future changes. I further acknowledge upon scheduling I am consenting to any treatment deemed necessary or advisable including by not limited to x-rays, anesthetics, and the required procedure.
Signature
*
Date
*
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Month
-
Day
Year
Date
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