Medical History Patient Name ______________________________ WELCOME, Please take the time to complete this form with your current medical information. You, and your families medical history will influence your susceptibility to certain dental conditions. The following information should be as complete and accurate as possible as we use it to select the most appropriate dental care for you. Please inform us of any changes to your medical history in the future.
Physician's Name _________________________________Physician's Address _________________________________Date of your last medical physical:__________ Are you currently under the care of a physician? Y / N Why?____________________________________________________________________________________________Please check any of the following conditions that you have or have had in the past:______ Abnormal Bleeding ______ Hepatitis, Type: ______ Anemia/Blood disorders ______ Herpes/Cold Sores/Shingles ______ Any heart problems ______ Kidney/Liver Problems ______ Arthritis/Rheumatism ______ Mental/Emotional Disorders ______ Artificial Heart Valve Implant ______ Nervous Problems ______ Asthma/Hay fever ______ Organ Transplant, Type: ______ Blood Pressure Problems: High / Low ______ Osteoporosis ______ Cancer, Type: ______ Prosthetic Joint Replacement Date: ______ Difficulty Breathing ______ Radiation or Chemotherapy Why: ______ Epilepsy or Seizures ______ Rheumatic Fever ______ Fainting or Dizzy Spells ______ Sinus Problems ______ Frequent Headaches, shoulder or neck aches ______ Stomach Problems ______ Glaucoma or light sensitivity ______ Stroke ______ Heart murmur ______ Tested Positive for HIV ______ Diabetes: Type 1 or Type 2 ______ Thyroid: Hypothyroid/Hyperthyroid Date Diagnosed_______________ Controlled or Uncontrolled? By Medication or Diet?
Have you ever taken Bisphosphonates such as Actonel, Boniva, Didronel, or Fosamax? Y /N If yes, what:____________Have you ever taken any prescription weight loss products? Y / N If yes, what:_________________________________Have you ever had a serious illness or major surgery not listed above? Y / N If yes, please explain: ________________
___________________________________________________________________________________Is there a family history of Diabetes, Heart Disease, Oral Cancer, or Periodontal Disease? Y / N If yes, please explain:
___________________________________________________________________________________ Would you describe your stress level as high, average, or low? Circle one. Do you smoke, chew, use snuff, or any other forms of tobacco? Y / N Circle those that apply. How long have you used tobacco? ________________________ How much do you use? ________________________ Have you ever quit or thought about quitting? _________________ Are you interested in quitting?_________________ Please list any medications you are currently taking, Yes / No List All Allergies Include prescription and non-prescription:□ □ Aspirin □ □ Codeine □ □ Dental Anesthetics □ □ Erythromycin □ □ Jewelry or metals □ □ Latex □ □ Penicillin □ □ Sulfa
List any health related substances you take routinely. Include any vitamins, supplements, or natural products. If female, please answer the following: Are you taking Birth Control Pills? Y/ N Are you pregnant? Y / N If Yes, # of weeks_____ Are you nursing? Y / N I certify that the above information is complete and accurate. Patient/Guardian Signature___________________________________________________ Date:___________________Dentist's Initials____________________________________________________________ Date:___________________
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