Online Medical History PDF

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Medical History

Patient Name (Please Print)

Birth Date

Although dental personnel primarily treat the area on and around your mouth, your mouth is a part of your entire body. Health problems that your may have, or medication that you may be taking could have an important interrelationship with the dentistry you will receive.

Are you under a physician’s care now?

YES

NO

 If yes, explain

Have you ever been hospitalized/had a major operation?

YES

NO

 If yes, explain

Have you ever had a serious head or neck injury?

YES

NO

 If yes, explain

Are you taking any medications, pills, or drugs*?

YES

NO

 If yes, explain

Do you take, or have you taken, Phen-Fen or Redux?

YES

NO

 If yes, explain

Have you ever taken Fosamax, Boniva, Actonel or any

 

 

 

other medications containing bisphosphonates?

YES

NO

 If yes, explain

Are you on a special diet?

YES

NO

 If yes, explain

Do you use tobacco?

YES

NO

 If yes, explain

Do you drink alcohol?

YES

NO

 If yes, how much:

Do you use controlled substances?

YES

NO

 If yes, explain

WOMEN: Are you pregnant/trying to get pregnant?

YES

NO

 Est. Due Date: Nursing YES NO

 

 

Are you taking oral contraceptives?

YES

NO

 

 

 

 

 

 

 

Are you allergic to any of the following?

 

 

 

 

 

 

 

 

 

 

Aspirin Penicillin Codeine

Local Anesthetics

Acrylic Metal Latex Sulfa Drugs

Other

NO KNOWN ALLERGIES

 

Please explain:

 

 

Do you have, or have you had, any of the following:

 

 

 

 

 

 

 

 

 

 

AIDS/HIV Positive

YES

NO

Convulsions

YES

NO

 

Heart Pacemaker

YES

NO

 

Pain in Jaw Joints

YES

NO

Alzheimer's Disease

YES

NO

Cortisone Medicine

YES

NO

 

Heart Trouble/Disease

YES

NO

 

Parathyroid Disease

YES

NO

Anemia

YES

NO

Diabetes

YES

NO

 

Hemophilia

YES

NO

 

Psychiatric Care

YES

NO

Angina

YES

NO

Drug Addiction

YES

NO

 

Hepatitis A

YES

NO

 

Radiation Treatments

YES

NO

Arthritis/Gout

YES

NO

Easily Winded

YES

NO

 

Hepatitis B or C

YES

NO

 

Recent Weight Loss

YES

NO

Artificial Heart Valve

YES

NO

Emphysema

YES

NO

 

High Blood Pressure

YES

NO

 

Renal Dialysis

YES

NO

Artificial Joint

YES

NO

Epilepsy & Seizures

YES

NO

 

High Cholesterol

YES

NO

 

Rheumatic Fever

YES

NO

Asthma

YES

NO

Excessive Bleeding

YES

NO

 

Hives or Rash

YES

NO

 

Rheumatism

YES

NO

Blood Disease

YES

NO

Excessive Thirst

YES

NO

 

Hypoglycemia

YES

NO

 

Shingles

YES

NO

Blood Transfusion

YES

NO

Fainting /Dizziness

YES

NO

 

Irregular Heartbeat

YES

NO

 

Sickle Cell Disease

YES

NO

Breathing Problem

YES

NO

Frequent Cough

YES

NO

 

Kidney Problems

YES

NO

 

Sinus Trouble

YES

NO

Bruise Easily

YES

NO

Frequent Headaches

YES

NO

 

Leukemia

YES

NO

 

Stomach/Intestinal Disease

YES

NO

Cancer

YES

NO

Genital Herpes

YES

NO

 

Liver Disease

YES

NO

 

Stroke

YES

NO

Chemotherapy

YES

NO

Glaucoma

YES

NO

 

Low Blood Pressure

YES

NO

 

Swelling of Limbs

YES

NO

Chest Pains

YES

NO

Hay Fever

YES

NO

 

Lung Disease

YES

NO

 

Thyroid Disease

YES

NO

Cold Sores/Fever Blisters

YES

NO

Heart Attack/Failure

YES

NO

 

Mitral Valve Prolapse

YES

NO

 

TB or Respiratory Disease

YES

NO

Congenital Heart Disorder

YES

NO

Heart Murmur

YES

NO

 

Osteoporosis

YES

NO

 

Yellow Jaundice

YES

NO

Have you ever had any serious illness not listed above? YES

NO Explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*If you have any additional medications you may list them on the back of the form. A copy can be scanned into your chart.

 

Signature of Patient, Parent, Guardian

 

Date

 

 

Doctor Signature

 

 

Date

 

 


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