Patient Name:
Age:
Name of Physician / and their specialty:
Most recent physical examination:
Purpose:
What is your estimate of your general health?
Excellent
Good
Fair
Poor
HAVE YOU EVER HAD THE FOLLOWING:
YES
NO
HAVE YOU EVER HAD THE FOLLOWING:
YES
NO
1. hospitalization for illness or injury
26. osteoporosis/osteopenia(taking bisphosphonates)
2. allergic reaction to
27. arthritis
aspirin, ibuprofen, acetaminophen
28. glaucoma
penicillin
29. contact lenses
erythromycin
30. head or neck injuries
codeine
31. epilepsy, convulsions (seizures)
local anesthetic
32. neurological problems (attention deficit disorder)
fluoride
33. viral infections and cold sores
metals (gold, stainless steel)
34. any lumps or swelling in the mouth
latex
35. hives, skin rash, hay fever
any other medications
36. STD / HPV / STI
3. heart problems or cardiac stent
37. hepatitis (type )
4. history of infective endocarditis
38. HIV / AIDS
5. artificial heart valve, repaired heart defect (PFO)
39. tumor, abnormal growth
6. pacemaker or implantable defibrillator
40. radiation therapy
7. orthopedic implant (joint replacement)
41. chemotherapy
8. rheumatic or scarlet fever
42. emotional problems
9. high or low blood pressure
43. psychiatric treatment
10. a stroke (taking blood thinners)
44. antidepressant medication
11. anemia or other blood disorder
45. alcohol / drug dependency
12. prolonged bleeding due to a slight cut
ARE YOU:
13. emphysema, sarcoidosis
46. presently being treated for any other illness
14. tuberculosis, measles, chicken pox
47. aware of any change in your general health
15. asthma
48. taking medication for weight management
16. breathing or sleep problems (i.e. snoring, sinus)
49. taking dietary supplements
17. kidney disease
50. often exhausted or fatigued
18. liver disease
51. experiencing frequent headaches
19. jaundice
52. a smoker or smoked previously
20. thyroid, parathyroid disease, or Ca. deficiency
53. considered a touchy / sensitive person
21. hormone deficiency
54. often unhappy or depressed
22. high cholesterol or taking statin drugs
55. easily upset or irritated
23. diabetes (HbA1c= )
56. FEMALE: taking birth control pills
24. stomach or duodenal ulcer
57. FEMALE: pregnant
25. digestive disorders (i.e. gastric reflux)
58. MALE: prostate disorders
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.
List any medications, supplements, and or vitamins taken within the last two years
DRUG
PURPOSE
DRUG
PURPOSE
Ask for an additional sheet if you are taking more than 6 medications
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR MEDICATIONS YOU MAY BE TAKING.
Patient's Signature
Date
Doctor's Signature
Date