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Medical History Form
MEDICAL HISTORY
What is your estimate of your general health?
Excellent
Good
Fair
Poor
DO YOU HAVE or HAVE YOU EVER HAD:
hospitalization for illness or injury
Yes
No
an allergic reaction to aspirin, ibuprofen, acetaminophen, codeine
Yes
No
an allergic reaction to penicillin
Yes
No
an allergic reaction to erythromycin
Yes
No
an allergic reaction to tetracycline
Yes
No
an allergic reaction to sulpha
Yes
No
an allergic reaction to local anesthetic
Yes
No
an allergic reaction to fluoride
Yes
No
an allergic reaction to metals (nickel, gold, silver)
Yes
No
an allergic reaction to latex
Yes
No
an allergic reaction to other:
heart problems or cardiac stent in last six months
Yes
No
history of infective endocarditis
Yes
No
artificial heart valve or repaired heart defect (PFO)
Yes
No
pacemaker or implantable defibrillator
Yes
No
artificial prosthesis (heart valve or joints)
Yes
No
rheumatic or scarlet fever
Yes
No
high or low blood pressure
Yes
No
a stroke (taking blood thinners)
Yes
No
anemia or other blood disorder
Yes
No
prolonged bleeding due to a slight cut (INR>3.5)
Yes
No
emphysema or sarcoidosis
Yes
No
tuberculosis
Yes
No
asthma
Yes
No
breathing or sleeping problems (snoring or sinus)
Yes
No
kidney disease
Yes
No
liver disease
Yes
No
jaundice
Yes
No
thyroid, parathyroid disease or calcium deficiency
Yes
No
hormone deficiency
Yes
No
high cholesterol or taking statin drugs
Yes
No
diabetes (HbA1c)
Yes
No
stomach or duodenal ulcer
Yes
No
digestive disorders (gastric reflux)
Yes
No
DO YOU HAVE or HAVE YOU EVER HAD: Continued.
osteoporosis/osteopenia (taking bisphosphonates)
Yes
No
arthritis
Yes
No
glaucoma
Yes
No
contact lenses
Yes
No
head or neck injuries
Yes
No
epilepsy or convulsions (seizures)
Yes
No
neurologic problems (ADD)
Yes
No
viral infections and cold sores
Yes
No
any lumps or swelling in the mouth
Yes
No
hives, skin rash or hay fever
Yes
No
venereal disease
Yes
No
hepatitis
Yes
No
HIV/AIDS
Yes
No
tumor or abnormal growth
Yes
No
radiation therapy
Yes
No
chemotherapy
Yes
No
emotional problems
Yes
No
psychiatric treatment
Yes
No
antidepressant medication
Yes
No
alcohol/drug dependency
Yes
No
ARE YOU:
presently being treated for any other illness
Yes
No
aware of a change in your general health
Yes
No
taking medication for weight management
Yes
No
taking dietary supplements
Yes
No
often exhausted or fatigued
Yes
No
subject to frequent headaches
Yes
No
a smoker or smoked previously
Yes
No
often unhappy or depressed
Yes
No
FEMALE-taking birth control pills
Yes
No
FEMALE-pregnant
Yes
No
MALE-prostate disorders
Yes
No
MEDICATION TREATMENT HISTORY
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 last two years
PLEASE ADVISE US OF ANY CHANGE IN YOUR MEDICATIONS OR MEDICAL HISTORY
PATIENT SIGNATURE
Signature of Patient/Legal Guardian:
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Date:
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