Medical History Form Fill Out Our Medical History Form Below Patient Name* Nickname Age*Name of Physician* Physician's Specialty* Most Recent Physical Examination* Physical Examination Purpose* Estimate of your general health?* Excellent Good Fair Poor DO YOU HAVE or HAVE YOU EVER HAD:1. hospitalization for illness or injury* YES NO 2. an allergic or bad reaction to any of the following:* NO ALLERGIES aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride chlorhexidine (CHX) metals (nickel, gold, silver, etc) latex nuts fruit milk red dye other 2. Other Allergies 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 or soft tissue implant (e.g joint replacement, breast implant)* YES NO 8. heart murmur, 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 (or INR > 3.5)* YES NO 13. pneumonia, emphysema, shortness of breath, sarcoidosis* YES NO 14. chronic ear infections, tuberculosis, measles, chicken pox* YES NO 15. breathing problems (e.g. asthma, stuffy nose, sinus congestion)* YES NO 16. sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)* YES NO 17. kidney disease* YES NO 18. liver disease or jaundice* YES NO 19. vertigo (e.g. ”the room is spinning”)* YES NO 20. thyroid, parathyroid disease, or calcium deficiency* YES NO 21. hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)* 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 or ever taken anti-resorptive medications (e.g. bisphosphonates)* YES NO 27. arthritis or gout* YES NO 28. autoimmune disease (e.g. 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* YES NO 38. hepatitis Type:* 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 or antidepressant medication* YES NO 45. concentration problems or ADD/ADHD diagnosis* YES NO 46. alcohol/recreational drug use* YES NO ARE YOU:47. presently being treated for any other illness* YES NO 48. aware of a change in your health in the last 24 hours (e.g., 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 or chronic pain* YES NO 53. a smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis)* YES NO 54. considered a touchy/sensitive person* YES NO 55. often unhappy or depressed* YES NO 56. taking birth control pills* YES NO 57. currently pregnant* YES NO 58. diagnosed with a prostate disorder* YES NO 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)List all medications, supplements, and or vitamins taken within the last two yearsDrug Purpose Drug Purpose Drug Purpose Drug Purpose PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.Patient's Signature* Date* MM slash DD slash YYYY CAPTCHA
