Medical History Form

* Denotes Required

Patient Name* :
Email*:
Nickname:
Age:
Name of Physician/and their specialty:
Most recent physical examination:
Purpose:
What is your estimate of your general health? ExcellentGoodFairPoor

DO YOU HAVE or HAVE YOU EVER HAD

1. Hospitalization for illness or injury? YESNO

2. An allergic reaction to

Aspirin, ibuprofen, acetaminophen, codeinePenicillinErythromycinTetracyclineSulphurLocal anaestheticFluorideMetals (nickel, gold, silver)LatexOther

If Other, please state

3. Heart problems or cardiac stent within the last six months YESNO
4. History of infective endocarditis YESNO
5. Artificial heart valve, repaired heart defect (PFO) YESNO
6. Pacemaker or implantable defibrillator YESNO
7. Artificial prosthesis (heart valve or joints) YESNO
8. Rheumatic or scarlet fever YESNO
9. High or low blood pressure YESNO
10. A stroke (taking blood thinners) YESNO
11. Anaemia or other blood disorder YESNO
12. Prolonged bleeding due to a slight cut (INR>3.5) YESNO
13. Emphysema, shortness of breath, sarcoidosis YESNO
14. Tuberculosis, measles, chicken pox YESNO
15. Asthma YESNO
16. Breathing or sleep problems (i.e. sleep apnea, snoring, sinus) YESNO
17. Kidney disease YESNO
18. Liver disease YESNO
19. Jaundice YESNO
20. Thyroid, parathyroid disease or calcium deficiency YESNO
21. Hormone deficiency YESNO
22. High cholesterol or taking statin drugs YESNO
23. Diabetes YESNO
State: HbA1c:
24. Stomach or duodenal ulcer YESNO
25. Digestive disorders (i.e. coeliac disease, gastric reflux) YESNO
26. Osteoporosis/osteopenia (i.e. taking bisphosphonates) YESNO
27. Arthritis, rheumatoid arthritis, lupus YESNO
28. Glaucoma YESNO
29. Contact lenses YESNO
30. Head or neck injuries YESNO
31. Epilepsy, convulsions (seizures) YESNO
32. Neurologic disorders (ADD/ADHD, prion disease) YESNO
33. Viral infections and cold sores YESNO
34. Any lumps or swelling in the mouth YESNO
35. Hives, skin rash, hay fever YESNO
36. STI/STD YESNO
37. Hepatitis YESNO
Which Type?
38. HIV / AIDS YESNO
39. Tumor, abnormal growth YESNO
40. Radiation therapy YESNO
41. Chemotherapy, immunosuppressive YESNO
42. Emotional problems YESNO
43. Psychiatric treatment YESNO
44. Antidepressant medication YESNO
45. Alcohol/street drug use YESNO

ARE YOU:

46. Presently being treated for any other illness YESNO
47. Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough
     or diarrhea)
YESNO
48. Taking medication for weight management YESNO
49. Taking dietary supplements YESNO
50. Often exhausted or fatigued YESNO
51. Experiencing frequent headaches YESNO
52. A smoker, smoked previously or use smokeless tobacco YESNO
53. Considered a touchy person YESNO
54. Often unhappy or depressed YESNO
55. FEMALE – taking birth control pills YESNO
56. FEMALE – pregnant YESNO
57. MALE – prostate disorders YESNO

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

If you are taking more than 8 medications, please state drug and purpose in the box below

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Patient's acceptance: Accepted

Today's date:

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