Medical History Form
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1MEDICAL 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
YES NO
1. hospitalization for illness or injury ______________________
26. osteoporosis/osteopenia (i.e. taking bisphosphonates) __
2. an allergic reaction to
27. arthritis, rheumatoid arthritis, lupus _________________
aspirin, ibuprofen, acetaminophen, codeine
28. glaucoma ______________________________________
penicillin
29. contact lenses __________________________________
erythromycin
30. head or neck injuries _____________________________
tetracycline
31. epilepsy, convulsions (seizures) _____________________
sulfa
32. neurologic disorders (ADD/ADHD, prion disease) _______
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. STI / STD ______________________________________
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, immunosuppressive _________________
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 / street drug use __________________________
11. anemia or other blood disorder _______________________
ARE YOU:
12. prolonged bleeding due to a slight cut (INR > 3.5) _________
13. emphysema, shortness of breath, sarcoidosis ____________
46. presently being treated for any other illness ___________
14. tuberculosis, measles, chicken pox _____________________
47. aware of a change in your health in the last 24 hours
15. asthma __________________________________________
(i.e. fever, chills, new cough, or diarrhea) ______________
16. breathing or sleep problems (i.e. sleep apnea, 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. experiencing frequent headaches ___________________
20. thyroid, parathyroid disease, or calcium deficiency ________
52. a smoker, smoked previously or use smokeless tobacco _
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. celiac disease, gastric reflux) _______
57. MALE - prostate disorders _________________________
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)
________________________________________________________________________________________________________________
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 _____________________
v 2012.2 Kois Center, LLC
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