MEDICAL HISTORY
Name:
Nickname:
Birthday:
Name of Physician and Specialty:
Date of Recent Physical Examination:
Purpose:
What is your estimate of your general health?
Excellent
Good
Fair
Poor
DO YOU HAVE or EVER HAD
YES
NO
1. Hospitalization for illness or injury:
Yes
No
2. An allergic reaction to:
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
metals (nickel, gold, silver)
latex
other:
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. Artificial Prosthesis (heart valve or joints):
Yes
No
8. Rheumatic or scarlet fever:
Yes
No
9. High or low blood pressure:
Yes
No
10. A stroke (taking blood thinners):
Yes
No
11. Anemia or other blood disorder:
Yes
No
12. Prolonged bleeding due to a slight cut (NR > 3.5):
Yes
No
13. Emphysema, sarcoidosis:
Yes
No
14. tuberculosis:
Yes
No
15. Asthma:
Yes
No
16. Breathing or sleep problems (i.e. 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 disorders (i.e. gastric reflux):
Yes
No
YES
NO
26. Osteoporosis/osteopenia (i.e. taking bisphosphonates):
Yes
No
27. Arthritis:
Yes
No
28. Glaucoma:
Yes
No
29. Contact lenses:
Yes
No
30. Head or neck injuries:
Yes
No
31. Epilepsy, convulsions (seizures):
Yes
No
32. Neurologic problems (attention deficit disorder):
Yes
No
33. Viral infections and cold sores:
Yes
No
34. Any lumps or swelling in the mouth:
Yes
No
35. Hives, skin rash, hay fever:
Yes
No
36. Venereal disease:
Yes
No
37. Hepatitis - type:
Yes
No
38. HIV/AIDS:
Yes
No
39. Tumor, abnormal growth:
Yes
No
40. Radiation therapy:
Yes
No
41. Chemotherapy:
Yes
No
42. Emotional problems:
Yes
No
43. Psychiatric treatment:
Yes
No
44. Antidepressant medication:
Yes
No
45. Alcohol / drug dependency:
Yes
No
ARE YOU:
46. Presently being treated for any other illness:
Yes
No
47. Aware of a change in your general health:
Yes
No
48. Taking medication for weight management (i.e. fen-phen):
Yes
No
49. Taking dietary supplements:
Yes
No
50. Often exhausted or fatigued:
Yes
No
51. Subject to frequent headaches:
Yes
No
52. A smoker or smoked previously:
Yes
No
53. Consider a touchy person:
Yes
No
54. Often unhappy or depressed:
Yes
No
55. FEMALE- taking birth control pills:
Yes
No
56. FEMALE- pregnant:
Yes
No
57. MALE- prostate disorders:
Yes
No
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.
List all medications, supplements, and or vitamins taken within the last two years
*Ask for an additional sheet if you are taking more than 6 medications
Patients Signature:
Date:
Doctors Signature:
Date:
Patient Validation:
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