Caringdentalcenter.biz

MEDICAL HISTORY
We appreciate the confidence you place with us to provide dental services. Assist us in serving
you by completing the following form. In the future, notify us of any changes in your health.
Patient Name: _________________________________ Primary M.D.: ____________________ Mailing Address ______________________ Phone (____) _________ Secondary M.D.: __________________ Mailing Address ______________________ Phone (____) _________ Previous dentist: __________________ Last dental visit: ____/____/____ Last medical exam: ____/____/____ PLEASE CIRCLE “YES” OR “NO” ON EACH OF THE FOLLOWING
Artificial heart valve ________________________ Yes No Do you smoke or chew tobacco? _______________ Yes No History of infective endocarditis _______________ Yes No How much? _______________________________ Certain specific, serious, congenital heart conditions: Are you allergic to or have you reacted adversely to any
• Cyanotic congenital heart disease: Unrepaired or of the following:
incompletely repaired (shunts and conduits?) __ Yes No Codeine, barbiturates, sedatives, sleeping pills ____ Yes No • Completely repaired congenital heart defect with Latex ____________________________________ Yes No prosthetic material or device (less than six months) Yes No Local anesthetics (“Novocain”)________________ Yes No • Repaired congenital heart defect with residual defect Penicillin or other antibiotics _________________ Yes No at or adjacent to the site of prosthetic patch/device Yes No Other ____________________________________ Cardiac transplants that develop valve problems __ Yes No Are you taking any of the following:
Arteriosclerosis ____________________________ Yes No Antibiotics or sulfa drugs ____________________ Yes No Blood pressure problem______________________ Yes No Anticoagulants (blood thinners), aspirin _________ Yes No Antidepressants ____________________________ Yes No Chest pain upon exertion _____________________ Yes No Cortisone (steroids) _________________________ Yes No Congenital heart malformations _______________ Yes No Digitalis, Nitroglycerin, or drugs for heart trouble _ Yes No Coronary occlusion or insufficiency ____________ Yes No High blood pressure medicine _________________ Yes No Heart attack _______________________________ Yes No Insulin, Orinase, or similar drug _______________ Yes No Heart murmur _____________________________ Yes No Tranquilizers ______________________________ Yes No Heart surgery ______________________________ Yes No Other _____________________________________________ Hypertrophic cardiomyopathy _________________ Yes No _____________________________________________ Mitral valve prolapse with valvular regurgitation __ Yes No Are you taking, or have you ever taken bisphosphonates
Pacemaker ________________________________ Yes No for chemotherapy or osteoporosis:
Rheumatic or other acquired heart valve problems _ Yes No Actonel, Boniva, Fosamax, IV Aredia, IV Zometa _ Yes No Stroke ___________________________________ Yes No Are you taking contraceptives or other hormones? _ Yes No Abnormal bleeding history ___________________ Yes No Are you pregnant? __________________________ Yes No Blood disease (anemia) ______________________ Yes No If so, expected delivery date: ____/____/____ Do you have any diseases or conditions not listed above? If so, Hepatitis _________________________________ Yes No please explain: ________________________________________ _____________________________________________________ Kidney Problems _________________________ Yes No _____________________________________________________ Allergy problems ________________________ Yes No Have your ever had adverse reactions with dental treatment? If so, please explain: ________________________________________ Asthma, Emphysema ________________________ Yes No _____________________________________________________ Tuberculosis ______________________________ Yes No To the best of my knowledge, all of the preceding answers are true and correct. If I have any change in my health or medications, I will inform the doctor at future appointments. I grant permission for my Arthritis __________________________________ Yes No physician to be contacted for details and advice. I further authorize Joint replacement ___________________________ Yes No the taking of radiographs, photographs, or other diagnostic measures appropriate for a thorough evaluation. Authorizations is also given Seizures or Epilepsy ________________________ Yes No for dental treatment to be rendered by the dentist and office staff.
Diabetes ________________________________ Yes No _______________________________________ ____/____/____ Signature: Patient / Parent / Guardian
Cancer/Tumor ( Past or Present ) ____________ Yes No Radiation: Head/Neck Region ( Past or Present ) __ Yes No _______________________________________ ____/____/____ Chemotherapy: ( Past or Present ) ______________ Yes No Signature: Patient / Parent / Guardian
Herpes, Venereal Disease, HIV+, AIDS _______ Yes NoAlcoholism _____________________________ Yes No Dr. Homer Initials: ____________ ____/____/____

Source: http://caringdentalcenter.biz/pdf/Medical%20History.pdf