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MEDICAL HISTORY
Patient Name
First Name
Last Name
Nickname
Date Of Birth
Date
Name of Physician/and their specialty
Most recent physical examination
Purpose
What is your estimate of your general health?
PLEASE ANSWER YES OR NO TO THE FOLLOWING
DO YOU HAVE or HAVE YOU EVER HAD
1. hospitalization for illness or injury
1
2. an allergic or bad reaction to any of the following:
2
3. heart problems, or cardiac stent within the last six months
3
4. history of infective endocarditis
4
5. artificial heart valve, repaired heart defect (PFO)
5
6. pacemaker or implantable defibrillator
6
7. orthopedic or soft tissue implant (e.g joint replacement, breast implant)
7
8. heart murmur, rheumatic or scarlet fever
8
9. high or low blood pressure
9
10. a stroke (taking blood thinners)
10
11. anemia or other blood disorder
11
12. prolonged bleeding due to a slight cut (or INR > 3.5)
12
13. pneumonia, emphysema, shortness of breath, sarcoidosis
13
14. chronic ear infections, tuberculosis, measles, chicken pox
14
15. breathing problems (e.g. asthma, stuffy nose, sinus congestion)
15
16. sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
16
17. kidney disease
17
18. liver disease or jaundice
18
19. vertigo (e.g. ”the room is spinning”)
19
20. thyroid, parathyroid disease, or calcium deficiency
20
21. hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)
21
22. high cholesterol or taking statin drugs
22
23. diabetes (HbA1c = )
23
24. stomach or duodenal ulcer
24
25. digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia,
anorexia)
25
26. osteoporosis/osteopenia or ever taken anti-resorptive
medications (e.g. bisphosphonates)
26
27. arthritis or gout
27
28. autoimmune disease
(e.g. rheumatoid arthritis, lupus, scleroderma)
28
29. glaucoma
29
30. contact lenses
30
31. head or neck injuries
31
32. epilepsy, convulsions (seizures)
32
33. neurologic disorders (e.g. Alzheimer’s disease, dementia, prion disease)
33
34. viral infections and cold sores
34
35. any lumps or swelling in the mouth
35
36. hives, skin rash, hay fever
36
37. STI/STD/HPV
37
38. hepatitis (type )
38
39. HIV/AIDS
39
40. tumor, abnormal growth
40
41. radiation therapy
41
42. chemotherapy, immunosuppressive medication
42
43. emotional difficulties
43
44. psychiatric treatment or antidepressant medication
44
45. concentration problems or ADD/ADHD
45
46. alcohol/recreational drug use
46
ARE YOU
47. presently being treated for any other illness
47
48. aware of a change in your health in the last 24 hours
48
49. taking medication for weight management
49
50. taking dietary supplements, vitamins, and/or probiotics
50
51. often exhausted or fatigued
51
52. experiencing frequent headaches or chronic pain
52
53. a smoker, smoked previously or other (e.g. smokeless tobacco,
vaping, e-cigarettes, and cannabis)
53
54. considered a touchy/sensitive person
54
55. often unhappy or depressed
55
56. taking birth control pills
56
57. currently pregnant
57
58. diagnosed with a prostate disorder
58
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 taken within the last two years.
Drug
Purpose
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
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