Form

Medical, Dental & Medication Information

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

First Name

Last Name

Birth Date

Medical Information and History

Primary Care Doctor Name:

Date of Last Medical Exam:

Preferred Pharmacy:

Are you currently under the care of a medical provider (i.e. Cardiologist, Orthopedic Surgeon, other specialist)?

Specialty Doctor Name:

Specialty Doctor Name:

Specialty Doctor Name:

Specialty Doctor Name:

Have you been told you can't undergo dental treatment?

<--- If yes, state here why and what treatment?

Have you ever been hospitalized or had any surgical operations within the last 5 years?

<--- If yes, please list Doctor Name, type of surgery and dates:

Have you ever had surgery to correct your airway/breathing including nasal surgery, tonsillectomy, and adenoidectomy?

<--- If yes, please list Doctor Name, type of surgery and dates:

Have you been told you need to premedicate with antibiotics or do you take a sedative prior to invasive dental treatment?

<--- If so, please list why and the medication used:

Are you taking any medication(s) including over the counter supplements?

<-----If you answered yes to this question, please list all medications on the Medication List Form (including PAP therapy for sleep apnea).

Are you taking Aspirin or any other Blood Thinner?

<--- INR if applicable:

Have you ever taken Alendronate (Fosamax), Risedronate (Actonel), Ibandronate (Boniva), and Zoledronic acid (Reclast), any other osteoporosis medications or any cancer medications containing bisphosphonates?

<--- Dates, or Currently taking?

Do you take, or have you taken, Phen-Fen or Redux?

Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?

Do you use tobacco / nicotine products?

Do you use a controlled substance?

Do you wear contact lenses?

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more then 3 weeks)?

Do you have any known allergies?

Please list any medication allergies you have and what reaction occurs when taken:

WOMEN ARE YOU:

# Number of weeks pregnant (if applicable):

Do you have or have you had any of the following? (Answer yes or no, do not leave blank)

AIDS/HIV

If AIDS/HIV, Last CD4 Count

Hepatitis

Anemia / Blood Disorder

List condition (if applicable):

Fainting / Seizures

Epilepsy / Convulsions

Hay Fever / Seasonal Allergies / Nasal Congestion

Rheumatic fever

Respiratory Problems / Emphysema / COPD

Asthma

Diabetic Type

Last A1c # (if applicable)

Easily Winded / Mouth Breather

Leukemia

Frequently Tired

Thyroid Problem / Hormonal Imbalance

List (if applicable):

Sleep Apnea

If yes, how are you treating your Sleep Apnea

Joint Replacement

Joint Replacement Complications

List (if applicable):

Cancer

Type of Cancer:

if yes, is Cancer in remission

Radiation Therapy

List (if applicable):

Location on Body where Radiation was done (if applicable):

Chemo Therapy

List (if applicable):

Location on Body where Chemo was done (if applicable):

Arthritis

Recent weight loss/gain

Glaucoma

Stomach Problems / Acid Reflux (GERD,LPR)

High Blood Pressure

Low Blood Pressure

Mitral Valve Prolapse / Heart Murmur

Swollen Ankles / Edema

Angina / Chest Pain

Pacemaker / Defibrillator

Heart Attack

Date of Heart Attack

If yes, Stents Placed

Heart Disease / Heart Trouble

List (if applicable):

Congenital Heart Defect

List (if applicable):

Infective Endocarditis

Artificial Valve Replacement

Kidney Disease

Stage of Kidney Disease (if applicable):

Liver Diesase

Stage of Liver Disease (if applicable):

Stroke

If yes, Stents Placed

Date of Stroke (if applicable):

Organ Transplant

Type of Organ and Date of the Organ Transplant (if applicable):

Immunocompromised / Immunosuppressant use

List medication (if applicable):

Tuberculosis

If yes:

Tuberculosis treatment completed:

Mental Health Condition

List (if applicable):

List Other Medical Health Conditions not mentioned above:

Dental Information and History

Reason for today's visit

What are the treatment goals you would like to accomplish with our office:

Are you in pain?

Did you start a course of antibiotics recently?

Current or Previous Dentist's Name if establishing for general dental care:

Date of Last Dental Exam:

Date of Last Full Series of X-rays (FMX):

Date of Last Cleaning:

Type of Last Cleaning: Prophy / Perio Maintenance (SPT) / Root Planing (deep cleaning under the gums):

Please indicate any of the following problems by selecting the corresponding box:

If other, please explain

Do you wear dentures or partials?

Have you ever had any orthodontic treatment?

If yes, dates treated:

Orthodontists Name:

Do you like your smile?

Do you wish your teeth were whiter?

Are you interested in:

Please answer yes or no to these questions below:

Do you, or have you been told you snore?

Do you feel excessively tired or fatigued during the day?

Has anybody observed you holding your breath during sleep?

Do you or are you being treated for high blood pressure?

Medication List

Please list all perscribed and over-the-counter medications you take and list the condition it was prescribed for here.

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medication Name:

Condition for Medication:

Medical History Information:

Dental History Information:

Medication List – Current Medication Information:

Signature

Date