MEDICAL HISTORY
 
Patient Name
Nickname
Age
Name of Physician
Physician specialty
Most recent
physical examination
Purspose of
last examination
What is your estimate
of your general health?
Excellent
Good
Fair
Poor

  

Do you need antibiotics prior to dental appointments? Yes  No
If yes, what medication has been prescribed?


DO YOU HAVE or HAVE YOU EVER HAD:

Yes  No 1. hospitalization for illness or injury
Yes  No 2. an allergic or bad reaction to any of the following:
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
metals (nickel, gold, silver, )
latex
nuts
fruit
other
Yes  No 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. orthopedic implant (joint replacement)
Yes  No 8. rheumatic or scarlet fever
Yes  No 9. high or low blood pressure
Yes  No 10. astroke (taking blood thinners)
Yes  No 11. anemia or other blood disorder
Yes  No 12. prolonged bleeding due toa slight cut (INR > 3.5)
Yes  No 13. pneumonia, emphysema, shortness of breath, sarcoidosis
Yes  No 14. tuberculosis, measles, chicken pox
Yes  No 15. asthma
Yes  No 16. breathing or sleep problems (i.e. sleep apnea, 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 or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)
Yes  No 26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
Yes  No 27. arthritis
Yes  No 28. autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)
Yes  No 29. glaucoma
Yes  No 30. contact lenses
Yes  No 31. head or neck injuries
Yes  No 32. epilepsy, convulsions (seizures)
Yes  No 33. neurologic disorders (ADD/ADHD, prion disease)
Yes  No 34. viral infections and cold sores
Yes  No 35. any lumps or swelling in the mouth
Yes  No 36. hives, skin rash, hay fever
Yes  No 37. STI/STD/HPV
Yes  No 38. hepatitis (type =  )
Yes  No 39. HIV/AIDS
Yes  No 40. tumor, abnormal growth
Yes  No 41. radiation therapy
Yes  No 42. chemotherapy, immunosuppressive medication
Yes  No 43. emotional difficulties
Yes  No 44. psychiatric treatment
Yes  No 45. antidepressant medication
Yes  No 46. alcohol/recreational drug use
  
ARE YOU:
Yes  No 47. presently being treated for any other illness
Yes  No 48. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
Yes  No 49. taking medication for weight management
Yes  No 50. taking dietary supplements
Yes  No 51. often exhausted or fatigued
Yes  No 52. experiencing frequent headaches
Yes  No 53. a smoker, smoked previously or use smokeless tobacco
Yes  No 54. considered atouchy/sensitive person
Yes  No 55. often unhappy or depressed
Yes  No 56. taking birth control pills
Yes  No 57. currently pregnant
If yes, 
Due Date Treating OBGYN Physician Phone Number
Yes  No 58. diagnosed with a prostate disorder
  

Describe any current medical treatment, impending surgery, geneti velopment 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
1.
2.
3.
3.
4.
6.

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


 

Patient’s Signature Date
Doctor’s Signature



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Date



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