Medical History
| All fields marked with * are required. | |||||
| In dentistry we primarily treat the area in and around your mouth. However, health problems that you may have or medications that you are taking can have a significant impact on your oral health and our treatment. Thank you for answering the following questions. | |||||
| *Patient Name | |||||
| Medical Physician | |||||
| Physician Phone # | |||||
| *Date of Last Exam | |||||
| *Please select one of the following: | |||||
| *1. Are you currently under medical treatment or a physician’s care? | |||||
| *2. Have you been hospitalized for any surgical operation or serious illness within the last 5 years | |||||
| *Has a physician ever told you to pre-medicate with antibiotics before dental treatment? | |||||
| *4. Do you use tobacco? | |||||
| *5. Do you use controlled substances? | |||||
| *6. Have you ever had a serious head or neck injury? | |||||
| 7. Do you take, or have you ever taken: | |||||
| *Bisphosphonates (Fosamax, Boniva, Actonel, ...) | |||||
| *Blood Thinners (Coumadin, Plavix, ...) | |||||
| *Are you a woman? | |||||
| Do you have, or have you had, any of the following? | |||||
| Aerosol Transmissible Disease | |||||
| *Pertussis or Whooping Cough | |||||
| *Shingles | |||||
| *Strep | |||||
| Eating Disorder | |||||
| *Anorexia | |||||
| *Bulimia | |||||
| Heart Disease | |||||
| *Angina (chest pain) | |||||
| *Arrhythmia (irregular heart beat) | |||||
| *Artificial Heart Valve | |||||
| *Congenital Heart Disorder | |||||
| *Heart Attack or Failure | |||||
| *Heart Murmur | |||||
| *Heart Pace Maker | |||||
| *Heart Trouble/Disease | |||||
| *High Blood Pressure | |||||
| *Low Blood Pressure | |||||
| *Mitral Valve Prolapse | |||||
| *Rheumatic Heart Disease | |||||
| Respiratory Disease/Condition | |||||
| *Asthma | |||||
| *Bronchitis | |||||
| *Emphysema | |||||
| *Lung Disease | |||||
| *Pneumonia | |||||
| *Sinusitis | |||||
| *Sleep Apnea | |||||
| *Tuberculosis | |||||
| Blood Disease | |||||
| *Anemia | |||||
| *Bleeding Disorder | |||||
| *Deep Vein Thrombosis | |||||
| *Leukemia | |||||
| *Lymphoma | |||||
| Emotional Disorder | |||||
| *ADD/ADHD | |||||
| *Anxiety | |||||
| *Bipolar | |||||
| *Depression | |||||
| *Other | |||||
| Gastrointestinal | |||||
| *Acid Reflux | |||||
| *Ulcers | |||||
| Kidney Disease | |||||
| *Dialysis | |||||
| *Renal Failure/Insufficiency | |||||
| Prosthetics (artificial) | |||||
| *Do you have prosthetics (artificial) | |||||
| *Other | |||||
| Muscle/Bone/Connective Tissue Conditions | |||||
| *Arthritis | |||||
| *Fibromyalgia | |||||
| *Lupus | |||||
| *Osteoporosis | |||||
| *Sjogren's Syndrome | |||||
| Cancer or Tumor | |||||
| *Do you, or have you ever had cancer or a tumor? | |||||
| Endoctrine Disease | |||||
| *Diabetes | |||||
| *Thyroid Problems (Hypothyroidism or Hyperthyroidism) | |||||
| Infectious Disease | |||||
| *AIDS/HIV Positive | |||||
| *Human Papilomavirus (HPV) | |||||
| *Oral Herpes | |||||
| *Venereal Disease | |||||
| Neurologic Condition | |||||
| *Dementia/Alzheimer's Disease | |||||
| *Nerve Pain | |||||
| *Parkinson's | |||||
| *Stroke | |||||
| *Seizures/Epilepsy | |||||
| *TIA (transient ischemic attack) | |||||
| Liver Disease | |||||
| *Cirrhosis | |||||
| *Hepatitis | |||||
| *Have you ever had any serious illness not listed above? | |||||