Medical History
Patient Name: ______Nickname: _________Age:________________
Name of Physican/their speciality:
Most recent physical examination: ____________________________Purpose: _________________________________________________ What is the estimate of your general health? Fair Excellent Poor Good
1. Hospitalization for illness or injury 26. Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g bisphosphonates) 2. An allergic or bad reaction to any of the following:
aspirin, ibuprofen, acetaminophin, codeine 27. Arthritis or gout penicillin 28. Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma) erythromycin 29. Glaucoma tetracycline 30. Contact lenses sulfa 31. Head or neck injuries local anesthetic 32. Epilepsy, convulsions (seizures) fluoride 33. Neurologic disorders (e.g. Alzheimer's disease chlorhexidine (CHX) dementia, prion disease) iodine 34. Viral infections and cold sore metals (nickel, gold, silver, other) 35. Any lumps or swelling in the mouth latex 36. Hives, skin rash, hay fever nuts 37. STI/STD/HPV fruit 38. Hepatitis ( ) milk 39. HIV/AIDS red dye 40. Tumor, abnormal growth other 41. Radiation therapy 3. Heart attack or cardiac stent within the last 6 months 42. Chemotherapy, immunosuppressive medication 4. History of infective endocarditis 5. Artificial heart valve, repaired heart defect 43. Emotional difficulties 6. Pacemaker or implantable defibrillator 44. Psychiatric treatment or antidepressant medication 7. Orthopedic or soft tissue implant (i.e. joint replacement) 45. Concentration problems or ADD/ADHD 8. Heart murmur, rheumatic or scarlet fever 46. Alcohol/recreational drug use 9. High or low blood pressure 10. A stroke (taking blood thinners) 11. Anemia or other blood disorder 12. Prolonged bleeding due to a slight cut ( or INR >3.5) 13. Pneumonia, emphysema, shortness of breath, sarcoidosis 47. Presently being treated for any other illnesses 14. Chronic ear infections, tuberculosis, measles, chicken pox 48. Aware of a change in your health in the last 24 hours (e.g. fever, chills, new cough, or diarrhea) 15. Breathing problems (e.g asthma, sinus congestion) 49. Taking medication for weight management 50. Taking dietary supplements, vitamins and/or probiotics 16. Sleep problems ( e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting) 51. Often exhausted or fatigued 17. Kidney Disease 52. Experiencing frequent headaches or chronic pain 18. Liver disease or jaundice 53. A smoker, smoked previously or other (e.g. smokeless 19. Vertigo (i.e. "the room is spinning") tobacco, vaping, e-cigarettes, and cannabis) 20. Thyroid, parathyroid disease, or calcium deficiency 54. Considered a touchy/sensitive person 55. Often unhappy or depressed 21. Hormone deficiency or imbalance (e.g. PCOS) 56. Taking birth control pills 22. High cholesterol or taking statin drugs 57. Currently pregnant 23. Diabetes (HbA1c= ) 58. Diagnosed with a prostate disorder 24. Stomach or duodenal ulcer 25. Digestive or eating disorders (e.g celiac disease, gastric reflux, bulimia, anorexia) 25. Digestive or eating disorders (e.g celiac disease, gastric reflux, bulimia, anorexia) 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, vitamins, and/or probiotics taken within the last two years. Patient's Signature Doctor's Signature Date: Date