Medical History Form

Your Name (required) *

Nickname

Your Email (required) *

Age

Name of Physician/and their specialty *

Most recent physical examination *

Purpose

What is your estimate of your general health?ExcellentGoodFairPoor

1.Hospitalization for illness or injuryYesNo

2.Do you have any allergiesYesNo

If yes please check any that applyaspirin, ibuprofen, acetaminophen, codeine penicillinerythromycintetracyclinesulfa localanestheticfluoride metals (nickel, gold, silver)latexother

If choose other please state: *

3. Heart problems, or cardiac stent within the last six monthsYesNo

4. History of infective endocarditisYesNo

5. Artificial heart valve, repaired heart defect (PFO)YesNo

6. Pacemaker or implantable defibrillatorYesNo

7. Artificial prosthesis (heart valve or joints)YesNo

8. Rheumatic or scarlet feverYesNo

9. High or low blood pressureYesNo

10. A stroke (taking blood thinners)YesNo

11. Anemia or other blood disorderYesNo

12. Prolonged bleeding due to a slight cut (INR > 3.5)YesNo

13. Emphysema, sarcoidosisYesNo

14. TuberculosisYesNo

15. AsthmaYesNo

16. Breathing or sleep problems (i.e. snoring, sinus)YesNo

17. Kidney diseaseYesNo

18. Liver diseaseYesNo

19. JaundiceYesNo

20. Thyroid, parathyroid disease, or calcium deficiencyYesNo

21. Hormone deficiencyYesNo

22. High cholesterol or taking statin drugsYesNo

23. Diabetes (HbA1c)YesNo

24. Stomach or duodenal ulcerYesNo

25. Digestive disorders (i.e. gastric reflux)YesNo

26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)YesNo

27. ArthritisYesNo

28. GlaucomaYesNo

29. Contact lensesYesNo

30. Head or neck injuriesYesNo

31. Epilepsy, convulsions (seizures)YesNo

32. Neurologic problems (attention deficit disorder)YesNo

33. Viral infections and cold soresYesNo

34. Any lumps or swelling in the mouthYesNo

35. Hives, skin rash, hay feverYesNo

36. STI / STDYesNo

37. hepatitisYesNo

38. HIV / AIDSYesNo

39. Tumor, abnormal growthYesNo

40. Radiation therapyYesNo

41. ChemotherapyYesNo

42. Emotional problemsYesNo

43. Psychiatric treatmentYesNo

44. Antidepressant medicationYesNo

45. Alcohol / street drug useYesNo

46. Presently being treated for any other illnessYesNo

47. Aware of a change in your health (i.e. fever, new cough)YesNo

48. Taking medication for weight management (i.e. fen-phen)YesNo

49. Taking dietary supplementsYesNo

50. Often exhausted or fatiguedYesNo

51. Experiencing frequent headachesYesNo

52. A smoker, smoked previously or use smokeless tobaccoYesNo

53. Considered a touchy personYesNo

54. Often unhappy or depressedYesNo

55. FEMALE - taking birth control pillsYesNo

56. FEMALE - pregnantYesNo

57. MALE - prostate disordersYesNo

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) *

22. High cholesterol or taking statin drugs *

Purpose *

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