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Medical History
First Name
Last Name
Date Of Birth
Are you a:
Male/ Female
Have you had changes to your medical history since your last visit? If No, please select no and skip to bottom for signature.
Name of Physician/and their specialty
Most recent physical examination
Purpose
What is your estimate of your general health?
Do you have OR have you ever had:
Hospitalization for illness or injury:
Why?
An allergic or bad reaction to any of the following:
If other, please list:
Heart Problems, or cardiac stent within the last 6 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)
High or low blood pressure
A 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. poly cystic ovarian syndrom)
High cholesterol or taking statin drugs
Diabetes
Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
Osteoporosis/osteopenia or ever taken any anti-resorptive medications
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 and cold sores
Any lumps or swelling in the mouth
Hives, skin rash, hay fever
STI/STD/HPV
Hepatitis
HIV/AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy, Immunosuppressive medication
Emotional difficulties
Psychiatric treatment or antidepressant medication
Concentration problems or ADD/ADHD
Alcohol/recreational drug use
Are you:
Presently being treated for any other illness?
Please list:
Aware of a change in your health in the last 24 hours (e.g. fever, chills, new cough, or diarrhea)
Please list:
Taking medication for weight management
Please list:
Taking dietary supplements, vitamins, and/or probiotics
Please list:
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 sensitive/ touchy person
Taking birth control pills
Currently pregnant
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 taken within the last two years.
Please advise us in the future of any change to your medical history or any new medications you may be taking. Also, please advice us of any changes in your contact information.
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