Medical History
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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 ______________________
27. arthritis _______________________________________
2. an allergic reaction to
28. autoimmune disease ____________________________
aspirin, ibuprofen, acetaminophen, codeine
(i.e. rheumatoid arthritis, lupus, scleroderma)
penicillin
29. glaucoma _____________________________________
erythromycin
30. contact lenses __________________________________
tetracycline
31. head or neck injuries _____________________________
sulfa
32. epilepsy, convulsions (seizures) _____________________
local anesthetic
33. neurologic disorders (ADD/ADHD, prion disease) _______
fluoride
34. viral infections and cold sores ______________________
metals (nickel, gold, silver, ____________)
35. any lumps or swelling in the mouth __________________
latex
36. hives, skin rash, hay fever __________________________
other _____________________________________
37. STI / STD / HPV _________________________________
3. heart problems, or cardiac stent within the last six months __
38. hepatitis (type ___) ______________________________
4. history of infective endocarditis _______________________
39. HIV / AIDS _____________________________________
5. artificial heart valve, repaired heart defect (PFO) __________
40. tumor, abnormal growth __________________________
6. pacemaker or implantable defibrillator _________________
41. radiation therapy ________________________________
7. orthopedic implant (joint replacement) _________________
42. chemotherapy, immunosuppressive medication _______
8. rheumatic or scarlet fever ____________________________
43. emotional difficulties _____________________________
9. high or low blood pressure ___________________________
44. psychiatric treatment_____________________________
10. a stroke (taking blood thinners) _______________________
45. antidepressant medication ________________________
11. anemia or other blood disorder _______________________
46. alcohol / recreational drug use _____________________
12. prolonged bleeding due to a slight cut (INR > 3.5) _________
ARE YOU:
13. emphysema, shortness of breath, sarcoidosis ____________
14. tuberculosis, measles, chicken pox _____________________
47. presently being treated for any other illness ___________
15. asthma __________________________________________
48. aware of a change in your health in the last 24 hours
16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
(i.e. fever, chills, new cough, or diarrhea) ______________
17. kidney disease ____________________________________
49. taking medication for weight management
18. liver disease ______________________________________
50. taking dietary supplements ________________________
19. jaundice _________________________________________
51. often exhausted or fatigued _______________________
20. thyroid, parathyroid disease, or calcium deficiency ________
52. experiencing frequent headaches ___________________
21. hormone deficiency ________________________________
53. a smoker, smoked previously or use smokeless tobacco _
22. high cholesterol or taking statin drugs __________________
54. considered a touchy / sensitive person _______________
23. diabetes (HbA1c =_______) __________________________
55. often unhappy or depressed _______________________
24. stomach or duodenal ulcer __________________________
56. FEMALE - taking birth control pills ___________________
25. digestive disorders (i.e. celiac disease, gastric reflux) _______
57. FEMALE - pregnant ______________________________
26. osteoporosis/osteopenia (i.e. taking bisphosphonates) __
58. 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
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 _____________________
ASA
(1-6)
v 2013.2 Kois Center, LLC
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