Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Medical History Patient’s Name_____________________________ Name of medical doctor______________________ Date of last physical __________ Name of previous dentist______________________ Yes No Date of last exam__________ *Are you currently under the care of a physician? If so, for what? _____________________ Yes No * Has there been any change in your health within Have you ever taken the drug Fen-Phen? the past year? _______________________ *Have you ever had or been diagnosed with: Do you have osteoporosis? Infective endocarditis Have you ever taken bisphosphonates such as: Congenital heart defect Fosamax, Actonel, Aredia, Zometa, Boniva, High blood pressure Didronel, Skelial, etc to prevent bone Low blood pressure loss from osteoporosis? High cholesterol Prosthetic joint surgery Do you have any disease, condition or problem not Prosthetic heart valve listed? _____________________________________ Heart surgery Pacemaker/defibrillator Do you wear, or have you worn a CPAP? Anticoagulant therapy Do you snore or have sleep apnea? Heart attack Do you often feel exhausted or fatigued? Organ transplant Emphysema/sarcoidosis Do you have any specific dental concerns Asthma If so, what__________________________ Tuberculosis Any lumps or swelling in the mouth? Anemia Would you like to keep your remaining teeth? Blood problems Leukemia Do you smoke or chew tobacco? Diabetes (HbA1c=____) Amount _________How many years_______ Thyroid disorder Ulcer, colitis For Women: Hepatitis Is there any chance you could be pregnant? Liver disease Are you taking birth control pills? Kidney trouble Arthritis, Rheumatism Malignancies/cancer Please list any and all medications you are taking, including Chemotherapy herbal supplements? Venereal disease Drug Purpose Epilepsy/convulsions _____________________ ______________________ Neurological issues _____________________ ______________________ Drug/alcohol dependency _____________________ ______________________ Excessive bleeding(INR>3.5) _____________________ ______________________ Stroke (blood thinners?) Corticosteroid therapy * Any known allergies? Fainting spells, convulsions Specifically, Penicillin Psychiatric care Sulfa Head & neck radiation Latex Eye disorder (glaucoma) Hormone therapy HIV/AIDS ***Signature (patient or parent/guardian) ______________________________Date________________