Medical history

Patient Name

Preffered

Age

Name of Physician

Most recent physical examination

1. Hospitalization for illness or injury?YesNo

2. An allergic or bad reaction to any of the following: YesNo

• aspirin or codeine
• penicillin
• erythromycin
• sulfa
• local anesthetic
• metals (nickel, gold, silver)
  
• latex
• other
  

3. Heart problems, or cardiac stent within the last six months?YesNo

4. Artificial heart valve, repaired heart defect (PFO)?YesNo

5. Pacemaker or implantable defibrillator? YesNo

6. Orthopedic or soft tissue implant (e.g joint replacement, breast implant)? YesNo

7. Heart murmur?YesNo

8. Rheumatic or scarlet fever?YesNo

9. High blood pressure?YesNo

10. Low blood pressure?YesNo

11. Stroke (taking blood thinners)?YesNo

12. Anemia or other blood disorder? YesNo

13. Kidney disease?YesNo

14. Liver disease or jaundice? YesNo

15. Thyroid, parathyroid disease, or calcium deficiency? YesNo

16. Diabetes? (if yes which type) YesNo

17. viral infections and cold sores YesNo

18. Hepatitis? (if yes which type) YesNo

19. HIV/AIDS? YesNo

20. Radiation therapy, cancer, or chemotherapy? YesNo

ARE YOU:

21. Presently being treated for any other illness? YesNo

22. A smoker?YesNo

23. Taking birth control pills? YesNo

24. Currently pregnant? YesNo

25. Currently nursing? YesNo

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List all medications, supplements, and or vitamins taken within the last two years

Drug & Purpose 1

Drug & Purpose 2

Drug & Purpose 3

Drug & Purpose 4

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.