Form

Name of Medical Doctor

Doctor's Office Phone

Specialty

What is your estimate of your general Health?

Date of most recent physical examination

Purpose

Emergency Contact

Phone

Relationship

List all the medications and dosages you are now taking:

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)

Have you had an allergic or bad reaction to any of the following:

List any other medications or substances that have given you an allergic or adverse reaction:

DO YOU HAVE or HAVE YOU EVER HAD:

(Please check Yes or No for each condition)

Hospitalization for illness or injury

Heart problems, or cardiac stent within the last six months

History of infective endocarditis

Artificial heart valve, repaired heart defect (PFO)

Pacemaker or implantable defibrillator

Orthopedic or soft tissue implant (e.g., joint replacement, breast implant)

Please describe:

Heart murmur, rheumatic or scarlet fever

High Blood Pressure

Low Blood Pressure

Stroke

Taking blood thinners

Anemia or other blood disorder

Prolonged bleeding due to a slight cut (or INR>3.5)

Pneumonia, emphysema, shortness of breath, sarcoidosis

Chronic ear infections, tuberculosis, measles, chicken pox

Breathing problems (e.g., asthma, stuffy nose, sinus congestion)

Sleep problems (e.g., sleep apnea, snoring, insomnia,restless sleep, bedwetting)

Kidney disease

Liver disease or jaundice

Vertigo (e.g., "the room is spinning")

Thyroid, parathyroid disease, or calcium deficiency

Hormone deficiency or imbalance (e.g., polycystic ovarian syndrome)

High cholesterol or taking statin drugs

Diabetes

HbA1c=

Stomach or duodenal ulcer

Digestive or eating disorders (e.g., gastric reflux, bulimia, anorexia, celiac disease, Crohn's disease, or any inflammatory bowel disease)

Osteoporosis/osteopenia or ever taken bone loss prevention drugs (anti-resporptive drugs such as Actonel, Fosamax, Boniva or any other Bisphosphonates)

List Bisphosphonates Taken:

Arthritis or gout

Autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma)

Glaucoma

Contact lenses

Head or neck injuries

Epilepsy, convulsions (seizures)

Neurologic disorders (e.g., Alzheimer's disease, dementia, prion disease)

Viral infections (e.g. cold sores)

Bacterial infections (e.g., Lyme disease)

Any lumps or swelling in the mouth

Hives, skin rash, hay fever

STI/STD/HPV

Hepatitis

Text

HIV/AIDS

Tumor, abnormal growth

Radiation therapy

Chemotherapy, immunosuppressive medication

Difficulties with stress management

Psychiatric treatment, antidepressants, mood stabilizing medications

Concentration problems or ADD/ADHD

Alcohol/recreational drug use

ARE YOU:

(Please check Yes or No for each condition)

Presently being treated for any other illness

Please list any other disease, condition or problem

Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough or diarrhea

Taking medication for weight management

Taking dietary supplements, vitamins, and/or probiotics

Please describe:

Often exhausted or fatigued

Experiencing frequent headaches or chronic pain

A smoker, smoked previously or other (e.g., smokeless tobacco, vaping, e-cigarettes, and cannabis

Considered a touchy/sensitive person

Often unhappy or depressed

Diagnosed with a prostate disorder

Currently using Birth Control Prescriptions

Women: Pregnant

Nursing

Preferred Pharmacy

Pharmacy Phone

I give my consent for the doctor to retrive and send electronic prescription and medical history information

I have answered the above questions to the best of my knowledge. I will notify the doctor of any change in my health or medication. I understand that the information provided above is critical to a safe and efficient dental experience.

Patient Signature/Parent or Guardian Signature if Minor

Date