E.S.I. MEDICAL HISTORY

MEDICAL HISTORY

Please take a moment to let us know about your medical & dental history so we may provide you with the best possible care. All information is confidential.
PATIENT NAME*

First NameMiddle NameLast Name
PHYSICIAN'S NAME
PHONE #
Please enter a valid phone number.
1. Have you had any medical care within the past two years?

YESNO
Describe
2. Have you taken any medication or drugs during the past two years?

YESNO
If yes, list medications here
3. Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosage of aspirin?

YESNO
If yes, please list names and dosage
What pharmacy do you use (name, city, phone #)?
4. Have you ever taken prescription medications for weight loss (diet pills)?

YESNO
If yes, did you take any of the following? CHECK ALL THAT APPLIES:

Fen-PhenPondimenReduxOther
If yes to any of the following above did you have a medical exam for heart issues?

YESNO
5. Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs?

YESNO
6. Are you aware of having an allergic ( or adverse) reaction to any substance or medication

YESNO
If yes, please specify
7. Have you been a patient in the hospital during the past five years?

YESNO

8. Indicate which of the following you have had, or have present. Check “Yes” or “No” to each item.*

	Yes	No
Heart (Surgery, Disease, Attack)
Chest Pain
Congential Heart Disease
Heart Murmur
Low Blood Pressure
High Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve/Pacemaker
Rheumatic Fever
Arthritis/Rheumatism
Cortisone Medicine
Swollen Ankles
Stroke
Diet (Special/Restricted)
Artificial Joints (Hip, Knee, etc.)
Kidney Trouble
Ulcers
Diabetes
Thyroid Problems
Glaucoma
Contact Lenses
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever
Allergy/Hives
Latex Sensitivity
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis A
Hepatitis B
Hepatitis C
Venereal Disease
A.I.D.S. / H.I.V. Positive
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Sickle Cell Disease
Bruise Easily
Liver Disease
Yellow Jaundice
Neurological Disorders
Epilepsy/Seizures
Fainting/Dizzy Spells
Nervous/Anxious
Psychiatric Care
Psychologial Care

9. Have you lost or gained more than 10 pounds in the past year?

YESNO
10. Do you have or have you had any disease, condition, or problem not listed?

YESNO
If yes, please list
11. Women: Are you pregnant or think you may be pregnant?

YESNO
If yes, How many months?
Are you nursing?

YESNO
12. Do you use birth control prescriptions?

YESNO
If yes, I understand antibiotics may interfere with birth control pills and that other contraceptive methods should be used while taking antibiotics. (Please initial):
I understand the above information is necessary to provide me wth dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.
Signature*

Clear
Date

MonthDayYear
Date

	Yes	No
Hot or Cold?
Sweets?
Biting or Chewing?
Have you noticed any mouth odors/bad tastes?
Do you frequently get cold sores/blisters/other?
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?
Does food get caught between your teeth? If yes, where (enter below)

	Yes	No
Orthodontic Treatment?
Oral surgery?
Your teeth ground or bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?

	Yes	No
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth? (pens, pencils, etc.)
Mouth breathe while you are awake or asleep?
Have tired jaws, especially in the morning?
Snore or have any other sleep disorders?
Smoke/chew tobacco or use other tobacco products?

	Yes	No
Clicking or popping of the jaw?
Pain? (joint, ear, side of face)
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Headaches, neckaches or shoulder aches?
Sore muscles? (neck, shoulders)

MEDICAL HISTORY