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Medical History Patient Name:_____________________________________________ Date:____________________________ Are you presently under a physician’s care? Y/ N Family physician_______________________________ _______________________________________________________ ___________________________________________________________________ If so, please specify Are you presently taking any medications (prescription or over-the counter)? Y / N If so, please specify________________________________________________________ ___________________________________________________________________ Are you currently taking or have you previously taken bisphosphonate medications, such as Actonel®, Fosamax® or Zometa, within the past twelve years? Y / N Do you, or have you had any of the following? Please check. ___ High blood pressure ___ Blood disorder (e.g. anemia) ___ Immune system disorder ___ Heart murmur or ___ Asthma (e.g. HIV) prolapsed valve (MVP) ___ Temporomandibular joint ___Kidney problems ___ Joint prosthesis(hip, knee, etc)problems (TMJ) ___ Psychiatric treatment ___ Rheumatic fever or rheumatic ___ Sinus trouble ___ Fainting spells or seizures heart disease ___ Thyroid problems ___ Epilepsy ___ Congenital heart disease ___ Diabetes ___ Cancer ___ Cardiovascular disease: ___ Stomach ulcers, colitis ___ Arthritis heart attack, stroke, by-pass ___ Hepatitis, jaundice, liver disease ___ Other__________________________ ___ Prosthetic heart valve ___ Alcoholism __________________________ If any of the above conditions are checked, is it or are they under control? Y / N If not, please specify________________________________________________________ ___________________________________________________________________ Are you allergic to any medication or anesthetic? Y / N Please list and also list reaction._______________________ ___________________________________________________________________ Are you allergic to latex? Y/N Have you been hospitalized in the last 5 years? Y / N Please list the reason and when this occurred. ____________ ___________________________________________________________________ Have you ever had root canal treatment? Y / N Do you need to premedicate prior to dental treatment for any of the following reasons? Y / N (Please check below) ___ Heart murmur or MVP ___ Joint prosthesis (hip, knee, etc) ___ Rheumatic Fever or Rheumatic heart disease ___ Prosthetic heart valve Are you pregnant? Y / N Are you taking birth control pills? Y / N If the answer is yes, please be advised that taking antibiotics can lessen the effect of the birth control pills. Please list anything else in your medical history of significance_______________________________________________ ___________________________________________________________________ How do you plan to pay for today’s visit? Patient (Parent’s) Signature: ___Cash ___ Check ___ Credit Card (MC, VISA or Discover) X_____________________________ Date: ________________________
