Medical History Medical History Patient NameBirthdate Month Day Year PhoneEmail Has there been any change in your general health in the past year? Yes No If so please describe:Date of last physical exam Month Day Year Are you now under a physician’s care for a particular problem? Yes No If so please describe:Have you had any serious illness, operations, or hospitalizations? Yes No If so please describe:Have you had any adverse effects from dental treatment or anesthesia? Yes No If so please describe:Do you have or have you ever had:Infective Endocarditis Yes No Born with Heart Defects Yes No Artificial heart valve Yes No Stents placed in arteries Yes No If so when?Do you require antibiotics prior to dental treatment? Yes No What type/dosage?Cardiovascular Disease Yes No Select Heart trouble Heart Attack Heart Murmur Coronary Artery Disease Angina Stroke TIA Palpitations Heart Surgery Pace Maker Chest Pain Do you carry Nitroglycerin with you? Yes No How often do you use it?High/Low Blood Pressure Yes No Lung Disease / Asthma Yes No Select Emphysema Chronic Cough Bronchitis Pneumonia Tuberculosis Shortness of Breath Severe coughing COPD Do you use an inhaler? Yes No Bleeding Disorder Yes No Select Blood thinners Tendency to bruise Anemia Bleeding tendency Blood transfusion? Artificial Joints placed anywhere in your body Hip, Knee, Shoulder Yes No Date (s) of surgeryRadiation or chemo treatment for cancer Yes No Type /YearLiver Disease Yes No Select Jaundice Hepatitis A B C Diabetes Yes No Select Type I Type II Most recent A1CBlood Sugar LevelKidney Disease Yes No Seizures, Convulsions, Epilepsy Yes No Fainting, Dizziness Yes No Psychiatric treatment Yes No Nervous/Anxiety disorder Yes No Hypoglycemia Yes No Acid Reflux or GERD or Heart Burn Yes No Thyroid Disease Yes No Select Goiter Hypothyroid Hyperthyroid Arthritis Yes No Stomach Ulcers/ Colitis Yes No Glaucoma Yes No Frequent or recurring mouth sores Yes No Sleep apnea Yes No Do you use a CPAP machine? Yes No Day time sleepiness? Yes No Sinus or nasal problems Yes No Have you had a recent injury to your head/jaw? Yes No Have you been treated for a jaw joint problem? Yes No Clicking / popping of jaw joint, pain near ear, difficulty opening your mouth? Yes No Do you grind or clench your teeth? Yes No Do you have frequest headaches? Yes No Sexually transmitted diseases, HIV/AIDS, HPV, Yes No Select HIV/AIDS HPV Any disease, drugs or transplant operation that has suppressed your immune system? Yes No Alcohol or Drug addiction Yes No Please list any medication you are currently taking, including any aspirin, vitamins or herbal/homeopathic supplements:Are you allergic to or have you had a bad reaction to any of the following?Local anesthetic (novocaine, xylocaine, etc) Penicillin, Amoxicillin, Sulfa, Cephalosporins, Tetracycline, Erythromycin, or other antibiotics Barbiturates, Valium, or other sedatives, etcFood Allergies (i.e.: eggs,milk,shellfish etc...)Aspirin, Acetaminophen, or IbuporfenCodeine, Demerol, Percodan or other pain killersLatex Other allergic reactions:History of Bisphosphonate treatment (Fosamax, Boniva, Actonel, Atelvia, Reclast, Alendronate, Ibandronate, Risedronate, Zoledronic) Yes No Do you smoke or chew tobacco? Yes No If so, how much per day & for how many yearsDo you have any other disease, condition or problem not listed above that you think the doctor should know about? Yes No If so what?Do you wish to speak with the doctor privately about anything? Yes No Are you pregnant, or is there a possibility that you may be pregnant? Yes No Are you nervous about having dental treatment? Yes No Have you ever had a bad dental experience? Yes No Do your gums bleed? Yes No Have you had periodontal disease or periodontal surgery? Yes No Are your teeth sensitive to cold / heat / pressure / sweet etc? Yes No Previous dentist’s nameImmediate dental concernIf you could change anything about your smile what would it be?I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment or amount that my insurance does not covePatient Name (printed)Patient (parent/guardian) signatureDate Month Day Year CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
