Medical History
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2LSU F
D
P
ACULTY
ENTAL
RACTICE
M
H
F
EDICAL
ISTORY
ORM
Name:
Date:
Date of Birth:
Sex: M / F
Height:
Weight:
For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered
confidential.
1.
Are you in good health? ............................................................................................................................................................ Yes
No
2.
Has there been any change in your health in the past year? ...................................................................................................... Yes
No
3.
My last physical exam was on
/
/
4.
Are you now under the care of a physician? ............................................................................................................................. Yes
No
If so, for what condition?
5.
The name and address of my physician is:
6.
Have you had any serious illness, operation or hospitalization within the past 5 years? .......................................................... Yes
No
7.
Are you taking any medicine(s) including non-prescription, homeopathic or “natural” remedies including diet pills? ........... Yes
No
If so, please list:
8.
Do you use any tobacco products?……………………………………………………………………………………………..Yes
No
If so, what kind and how often?________________________________________________________________________________
Are you interested in a smoking cessation program? …………………………………………………………………………..Yes No
9.
Do you drink alcohol?................................................................................................................................................................Yes No
If so, how many drinks per week?______________________________________________________________________________
10. Do you use any recreational drugs?............................................................................................................................................Yes No
11. Do you have or have you had any of the following diseases or problems?
Damaged heart valves, artificial valves, heart murmur
Y N
Hepatitis, jaundice or liver disease
Y
N
or pacemaker
Rheumatic heart disease
Y N
Frequent or recurring mouth sores
Y
N
Heart trouble, heart attack, angina , arteriosclerosis or
Y N
Thyroid problems
Y
N
any other heart condition
Chest pain upon exertion
Y N
Respiratory problems, emphysema, bronchitis, etc
Y
N
Shortness of breath after mild exercise
Y N
Stroke
Y
N
Do your ankles swell
Y N
Stomach ulcer or hyperacidity
Y
N
Allergies
Y N
Kidney trouble
Y
N
Sinus trouble
Y N
Tuberculosis
Y
N
Asthma or hay fever
Y N
Persistent cough or cough that produces blood
Y
N
Fainting spells or seizures
Y N
Persistent swollen neck glands
Y
N
Diabetes
Y N
High or Low blood pressure
Y
N
Cancer
Y N
Epilepsy or neurological disorder
Y
N
Any disease, drug or transplant operation that has depressed
Arthritis; Painful, swollen joints including jaw joint
Y N
Y
N
your immune system
(TMJ)
12. Have you had abnormal bleeding? ............................................................................................................................................ Yes
No
a.
Have you ever required a blood transfusion? ..................................................................................................................... Yes
No
13. Do you have any blood disorder such as anemia? .................................................................................................................... Yes
No
14. Have you ever had treatment for a tumor or growth? ............................................................................................................... Yes
No
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