Medical History Form Patient InformationPatient Name First Last AgePlease enter a number from 1 to 110.PhoneEmail Name of Physician/and their specialty Most recent physical examination Purpose What is your 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: Yes No Allergic Items: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride chlorhexidine (CHX) metals (nickel, gold, silver) latex nuts fruit milk reddye hives skin rash hay fever other Other Allergic Items 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. joint replacement or heart valve replacement Yes No 8. heart murmur, rheumatic or scarlet fever Yes No 9. high blood pressure Yes No 10. low blood pressure Yes No 11. stroke (taking blood thinners) Yes No 12. anemia or other blood disorder Yes No 13. prolonged bleeding due toa slight cut (or INR greater than 3.5) Yes No 14. pneumonia, emphysema, shortness of breath, sarcoidosis Yes No 15. chronic ear infections, tuberculosis, measles, chicken pox Yes No 16. breathing problems (e.g. asthma, stuffy nose, sinus congestion) Yes No 17. sleep problems (e.g. sleep apnea, snoring, insomnia or restless sleep) Yes No 18. kidney disease Yes No 19. liver disease or jaundice Yes No 20. vertigo (e.g. ”the room is spinning”) Yes No 21. thyroid, parathyroid disease, or calcium deficiency Yes No 22. hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome) Yes No 23. high cholesterol or taking statin drugs Yes No 24. diabetes Yes No 25. stomach or duodenal ulcer or 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. head or neck injuries Yes No 31. epilepsy, convulsions (seizures) Yes No 32. neurologic disorders (ADD/ADHD, prion disease) 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. hepatitis Yes No Type 37. HIV/AIDS Yes No 38. tumor, abnormal growth Yes No 39. radiation therapy Yes No 40. chemotherapy, immunosuppressive medicationchemotherapy, immunosuppressive medication Yes No 41. medication treatment or antidepressant medication (Autism, Sensory Issues, ADHD) Yes No 42. recreational drug use Yes No Are You:43. presently being treated for any other illness Yes No 44. experiencing frequent headaches or chronic pain Yes No 45. a smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis) Yes No 46. currently pregnant Yes No 47. diagnosed with a prostate disorder Yes No Additional InformationDescribe 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 1 Drug & Purpose 2 Drug & Purpose 3 Drug & Purpose 4 SignaturePLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.Print Patient or Patient's Authorized representative Date Month Day Year SignatureRelationship of status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.) CAPTCHA Δ
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