Download Medical History Form (Page 1)

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________________