Medical History
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1
2Medical History
Patient Name: ____________________________________________________ Date of Birth: __________________
1. Date of last physical exam: _______________________ Physician's Name: ______________________________________________
Physician’s Phone#: ____________________________________________
2. Have you ever been hospitalized (if yes, explain below)? Yes No
______________________________________________________________________________________________________________________________
3. Have you been under the care of a medical doctor during the past two years?
Yes No
If yes, what for? _________________________________________________________________________________________________
4. Have you ever had any excessive bleeding requiring special treatment?
Yes No
5. Women: Are you pregnant/trying to get pregnant/breast feeding?
Yes No
6. Are you allergic to or have you had an allergic reaction to any of the following (please circle if yes):
Local Anesthetic
Penicillin
Codeine
Other Antibiotic: ____________________________
Latex
Acrylic
Metals
Other:_________________________________________
7. Are you taking or have you ever taken any of the following medications (please circle if yes):
Fosamax
Actonel
Boniva
For how long? _______________________________
Aredia
Reclast
Zometa
When did you stop? _________________________
8. Please list other medications you are taking:
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Have you ever had any of the following?
Chest Pains
Yes No
Shortness of Breath
Yes No
Hives/Skin Rashes
Yes No
Heart Failure
Yes No
Ulcers
Yes No
Alcoholism
Yes No
Heart Disease
Yes No
Mental Health Issues
Yes No
Herpes
Yes No
Heart Attack
Yes No
Emphysema
Yes No
Glaucoma
Yes No
Heart Problems
Yes No
Fainting/Dizziness
Yes No
Steroid Treatment
Yes No
Angina Pectoris
Yes No
Eating Disorder
Yes No
Arthritis
Yes No
Heart Surgery
Yes No
Epilepsy/Seizures
Yes No
Dental Implant
Yes No
Liver Disease
Yes No
Persistent Cough
Yes No
Dentures/Partials
Yes No
Hypertension
Yes No
Tuberculosis
Yes No
Birth Defects
Yes No
Heart Murmur
Yes No
Asthma
Yes No
HIV+, AIDS, ARC
Yes No
Rheumatic Fever Yes No
Hepatitis A
Yes No
Hay Fever
Yes No
Psychiatric
Treatment
Yes No
Hepatitis B
Yes No
Tobacco Products
Yes No
Alliance Dentistry NC Adult Medical History
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Parent category: Medical