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Legal Name:__________________________________________________________________________________________ Date of Birth: _______________________________ What is your estimate of your general health? អ Good Please list any physicians that you see at least once per year: Preferred Pharmacy Name & Location _________________________________________ 1. Do you have or have you ever had (circle all that apply): a. active tuberculosis (TB), persistent cough longer than 3 weeks, cough producing blood *** IF YOU ANSWERED YES TO ANY OF THE ABOVE ITEMS, PLEASE STOP AND RETURN THIS FORM TO THE RECEPTIONIST*** iii. penicillin, erythromycin, tetracycline, sulfa iv. aspirin, codeine, ibuprofen, acetaminophen v. metals (gold, stainless steel, nickel) c. heart disease, heart attack, angina, congestive heart failured. heart murmur or mitral valve prolapsee. pacemaker, defibrillator * f. bacterial endocarditis, artificial heart valve, congenital heart disease 1. Do you have or have you ever had (circle all that apply): h. strokei. bleeding problem, anemia, bruise easily, or other blood diseasej. emphysema, COPD, asthmak. sinus problemsl. kidney diseasem. liver disease, jaundice, hepatitis (A, B, C, or D)n. thyroid, parathyroid disease p. stomach or intestinal disease, reflux disease, or digestive disorderq. cancer, abnormal growth, chemotherapy, radiation therapy * r. immunosuppressive condition: (circle all that apply) * s. artificial joint(s): (list joint and date of placement) t. artificial implants or devicesu. muscle disease, joint disease, or arthritis (osteo or rheumatoid)v. glaucoma, impairment of sight, hearing, or speechw. head or neck injuriesx. frequent headachesy. epilepsy, seizures, nervous system diseasez. antibiotic therapy lasting more than 1 monthaa. mental health condition, emotional problems, psychiatric treatment, bb. physical or mental disabilities that may require special care 2. Have you taken medication or had IV therapy for osteoporosis or high blood calcium? (e.g. Fosamax, Actonel, Boniva-Pill, Boniva-IV, Aredia, Zometa) អ Yes អ No 3. Do you have any disease, condition, or problem not listed here? អ Yes អ No4. Do you have any undiagnosed symptoms? អ Yes អ No5. Have you been hospitalized for illness, injury, or had surgery in the last 6. Do you smoke or use smokeless tobacco? (list products that you use) អ Yes អ No7. Do you drink alcohol? អ Yes អ No8. Do you use recreational drugs? អ Yes អ No9. Are you, or have you ever been addicted to a chemical substance? (e.g. alcohol, prescription drugs, heroin, methamphetamine, cocaine) អ Yes អ No 10. Are you or could you be pregnant? Nursing? អ Yes អ No Doctor’s Signature _______________________________________________ Date ______ Patient/Legal Guardian’s Signature __________________________________ Date ______ POS® Reorder # 0722127

Source: http://www.gatewaydentalgroup.org/assets/docs/Medical-History-Form.pdf

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