Medical History - Blue printable pdf download

MEDICAL HISTORY

Patient Name ________________________________________________ Nickname ____________________ Age ________

Name of Physician/and their specialty _____________________________________________________________________

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

1. hospitalization for illness or injury ______________________

26. osteoporosis/osteopenia (i.e. taking bisphosphonates) __

2. an allergic reaction to

27. arthritis _______________________________________

aspirin, ibuprofen, acetaminophen, codeine

28. glaucoma ______________________________________

penicillin

29. contact lenses __________________________________

erythromycin

30. head or neck injuries _____________________________

tetracycline

31. epilepsy, convulsions (seizures) _____________________

sulpha

32. neurologic problems (attention deficit disorder) ________

local anesthetic

33. viral infections and cold sores ______________________

fluoride

34. any lumps or swelling in the mouth __________________

metals (nickel, gold, silver, ____________)

35. hives, skin rash, hay fever __________________________

latex

36. venereal disease ________________________________

other _____________________________________

37. hepatitis (type ___) ______________________________

3. heart problems, or cardiac stent within the last six months __

38. HIV / AIDS _____________________________________

4. history of infective endocarditis _______________________

39. tumor, abnormal growth __________________________

5. artificial heart valve, repaired heart defect (PFO) __________

40. radiation therapy ________________________________

6. pacemaker or implantable defibrillator _________________

41. chemotherapy __________________________________

7. artificial prosthesis (heart valve or joints) ________________

42. emotional problems _____________________________

8. rheumatic or scarlet fever ____________________________

43. psychiatric treatment_____________________________

9. high or low blood pressure ___________________________

44. antidepressant medication ________________________

10. a stroke (taking blood thinners) _______________________

45. alcohol / drug dependency ________________________

11. anemia or other blood disorder _______________________

12. prolonged bleeding due to a slight cut (INR > 3.5) _________

ARE YOU

13. emphysema, sarcoidosis ____________________________

14. tuberculosis ______________________________________

46. presently being treated for any other illness ___________

15. asthma __________________________________________

47. aware of a change in your general health _____________

16. breathing or sleep problems (i.e. snoring, sinus) ___________

48. taking medication for weight management (i.e. fen-phen)

17. kidney disease ____________________________________

49. taking dietary supplements ________________________

18. liver disease ______________________________________

50. often exhausted or fatigued _______________________

19. jaundice _________________________________________

51. subject to frequent headaches _____________________

20. thyroid, parathyroid disease, or calcium deficiency ________

52. a smoker or smoked previously ____________________

21. hormone deficiency ________________________________

53. considered a touchy person _______________________

22. high cholesterol or taking statin drugs __________________

54. often unhappy or depressed _______________________

23. diabetes (HbA1c =_______) __________________________

55. FEMALE - taking birth control pills ___________________

24. stomach or duodenal ulcer __________________________

56. FEMALE - pregnant ______________________________

25. digestive disorders (i.e. gastric reflux) ___________________

57. MALE - prostate disorders _________________________

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.

________________________________________________________________________________________________________________

List all 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 ANY MEDICATIONS YOU MAY BE TAKING

Patient’s Signature ______________________________________________________________________ Date _____________________

Doctor’s Signature ______________________________________________________________________ Date _____________________

v2.1 - 2010 Kois Center, LLC

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