Medical History

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?



36 N. San Mateo Drive, Suite B
San Mateo, 94401

Olson Dental

36 N. San Mateo Drive, Suite B

Mob: (650) 342-0474

MON - WED : 8:00 am - 5:00 pm

THU - FRI : 7:00 am - 3:30 pm

SAT - SUN : Closed