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MEDICAL HISTORY Patient Name____________________________________________ Nickname _____________________________ Age___________ Name of Physician and their specialty___________________________________________________________________________________ Date of most recent physical examination_____________________ Purpose________________________________________________ What is your estimate of your general health? Excellent Good Fair Poor DO YOU HAVE OR HAVE YOU EVER HAD: Yes No Hospitalization for illness or injury Heart problem Heart murmur Rheumatic Fever Scarlet Fever High blood pressure Low blood pressure A stroke Artificial prosthesis (i.e. heart valve or joints) Anemia or other blood disease Prolonged bleeding due to a slight cut Emphysema Tuberculosis Asthma Breathing/Sleep problems (i.e. snoring, sinus) Yes No Yes Kidney disease Liver disease Jaundice Thyroid or Parathyroid disease Hormone deficiency High Cholesterol Diabetes Stomach or duodenal ulcer Digestive disorders Osteoporosis/Osteopenia Arthritis Glaucoma Contact Lenses Head or neck injuries Epilepsy/Convulsions (seizures) No Neurologic Problems Viral infections and cold sores Any lumps/swelling in the mouth Hives, skin rash, hay fever Venereal disease Hepatitis (type_____) HIV/AIDS Tumor/abnormal growth Radiation therapy Chemotherapy Emotional Problems Psychiatric treatment Antidepressant medication Alcohol/drug dependency ARE YOU: ALLERGIC REACTION TO: Yes Presently being treated for any other illness Aware of a change in your general weight Taking medication for weight management Taking dietary supplements FEMALE - pregnant FEMALE – taking birth control pills No Yes No Yes A smoker or smoked previously Often unhappy or depressed Often exhausted or fatigued Subject to frequent headaches MALE – prostate disorders G.A.S.P. Questionnaire Yes Have you been told (or noticed on your own)that you snore on most nights? Have you been told (or noticed on your own) that you stop breathing or struggle to breathe in your sleep? Are you tired, fatigued or sleepy on most days? Do you have acid indigestion or high blood pressure (or use medication to control either of these conditions)? Are you overweight? Yes Total + Not sure Total = 0 1 2 3 Low Risk Medium Risk No Not Sure No Penicillin Erythromycin Tetracycline Codeine Local Anesthetic Fluoride Acetaminophen Latex Aspirin Metals (type________________) Ibuprofen Any other medication ______________________ 4 5 High Risk 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 PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING Signature____________________________________________________________ Relationship to Patient _________________________________________________ Date________________________________
