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Medical History
Patient Name (First and Last)
Date of Birth
Name of Physician and their specialty
Preferred Pharmacy
DO YOU or HAVE YOU EVER HAD:
1.Hospitalizations for illness or injury
2. An allergic or bad reaction to any of the following:
Asprin
Penicillin
Erythromycin
Tetracycline
Sulfa
Local Anesthetic
Fluoride
Chlorhexidine (CHX)
Iodine
Metals (nickel,gold,silver)
Latex
Nuts
Fruit
Milk
Red Dye
Other
3.heart problems, or cardiac stent within the last six months
4. history of infective enodarditis
5.artificial heart valve, repaired heart defect (PFO)
6.pacemaker or implantable difibrillator
7. orthopedic or soft tissue implant (e.g joint replacement, breast implant)
8. heart murmur, rheumatic or scarlet fever
9. high or low blood pressure
10. a stroke (taking blood thinners)
11. anemia or other blood disorder
12. prolonged bleeding due to slight cut (or INR>3.5)
13. pneumonia, emphysema,shortness of breath, sarcoidosis
14. chronic ear infections, tuberculosis,measles,chicken pox
15. breathing problems (eg asthma,stuffy nose, sinus congestion)
16.sleep problems (eg. sleep apnea,snoring,restless sleep,bedwetting)
17. kidney disease
18. liver disease or jaundice
19. Vertigo (e.g "the room is spinning")
20. thyroid, parathyroid disease or calcium dificiency
21. hormone deficiency or imbalance (e.g poly cystic ovarian syndrome)
22. high cholesterol or taking statin drugs
23. diabetes (HbA1c=
25. digestive or eating disorder (e.g celiac disease, gastric reflux, bulimia, anorexia)
26. osteoporosis/osteopenia or ever taken anti-resorptive medications (bisphosphonates)
27. arthritis or gout
28. autoimmune disease (e.g rheumatoid arthritis, lupus, scleroderma)
29. glaucoma
30. Contact lenses
31. head or neck injuries
32. epilepsy, convulsions (seizures)
33. neurologic disorders( e.g Alzheimer's disease, dementia, prion disease)
34. viral infections and cold sores
35. any lumps or swelling in the mouth
36. hives, skin rash hay fever
37. STI/STD/HPV
38. hepetitus Type:
39. HIV/AIDS
40. tumor, abnormal growth
41. radiation therapy
42. chemotherapy, immunosuppressive medication
43. emotional difficulties
44. Psychistric treatment or antidepressant medication
45. concentration problems or ADD/ADHD
46. alcohol/recreational drug use
Are you:
47. presently being treated for any other illness
48. aware of a change in your health in the last 24 hours ( fever, chills, new cough, diarrhea)
49. taking medication for weight management
50. taking dietary supplements, vitamins, and or probiotics
51. often exhausted or fatigued
52. experiencing frequent headaches or chronic pain
53. a smoker, smoked previously or other (smokeless tobacco,vaping, e-cigarettes, or cannabis)
54. considered a touchy/sensitive person
55. often unhappy or depressed
56. taking birth control pills
57. Currently pregnant
58. diagnosed with a prostate disorder
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, vitamins, and/or probiotics
Text
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.
By signing this document, I acknowledge that the answers I have provided above are true and accurate.
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