Medical History
Although dental personnel treat the area in and around your mouth, your mouth is a part of your entire body. Health conditions or problems that you may have or had, or medications you may be taking, could have an important interrelationship with the treatment you will receive. Thank you for answering the following questions.
Allergies or Sensitivities:
AcrylicsY N
CodeineY N
LatexY N
Local Anesthetics Y N
PenicillinY N
MetalY N
SulphaY N
Fragrances or chemicalsY N
OtherY N
List other allergies or sensitivities:
______
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Autoimmune:
Hashimoto’sY N
Rheumatoid arthritisY N
Crohn’s diseaseY N
Ulcerative colitisY N
Celiac diseaseY N
LupusY N
Sjogren’s syndromeY N
Type 1 diabetesY N
PsoriasisY N
Multiple sclerosisY N
Ankylosing spondylitisY N
Other autoimmune (specify)Y N
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Cardiovascular:
Artificial heart valve Y N
Coronary artery disease Y N
Chest pain or anginaY N
Congestive heart failureY N
Heart attackY N
Heart murmurY N
High blood pressureY N
High cholesterolY N
Irregular heart beatY N
Low blood pressureY N
Men: erectile dysfunctionY N
Mitral valve prolapseY N
PacemakerY N
TachycardiaY N
Endocrine:
DiabetesY N
GoutY N
Hormonal problemsY N
Thyroid problemsY N
Eyes, Ears, Nose and Throat:
Change in hearingY N
Change in visionY N
Dysphagia/difficulty swallowing
Y N
Ear painY N
GlaucomaY N
Hay feverY N
Seasonal allergiesY N Sinus problemsY N
TonsillectomyY N
TinnitusY N
White coating on tongueY N
Gastrointestinal:
Acid refluxY N
Soft or special diet Y N
Stomach ulcersY N
Hematological:
Bleeding problemsY N
HepatitisY N
HerpesY N
HIV/AIDSY N
Liver problemsY N
Musculoskeletal:
Back painY N
FibromyalgiaY N
Joint painY N
Joint replacementY N
ArthritisY N
Neurological:
Alzheimer’s diseaseY N
Brain fogY N
DizzinessY N
FaintingY N
Memory lossY N
Multiple sclerosisY N
Muscle weaknessY N
SeizuresY N
StrokeY N
Tingling/numbnessY N
Trigeminal neuralgiaY N
TremorY N
Psychiatric:
ADD/ADHDY N
AnxietyY N
Chemical dependencyY N
DepressionY N
Eating disordersY N
Excessive stressY N
Fatigue/tiredY N
Memory problemsY N
Respiratory:
AsthmaY N
BronchitisY N
Breathing problemsY N
Chest pressureY N
Dyspnea (shortness of breath)
Y N
EmphysemaY N
Orthopnea (shortness of breath when lying flat)Y N
PneumoniaY N
Pulmonary embolismY N
TuberculosisY N
Sleep:
Daytime sleepinessY N
Morning headachesY N
Sleep apneaY N
Do you use CPAP?Y N
SnoringY N
General:
Current approx. weight: ____lbs
Height: ______
Weight changeY N
CancerY N
Radiation treatmentY N
Do you smoke?Y N
Smokeless tobaccoY N
Recreational drugsY N
Women Only:
Are you pregnant?Y N
Trying to conceive?Y N
Pregnancy complicationsY N
MiscarriageY N
Difficulty conceivingY N
Are you breastfeeding?Y N
List any medications, vitamins or supplements you are taking. Include prescription and over-the-counter.
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Please list any surgeries or hospitalizations you have had.
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Please list and detail any medical condition or history not listed previously.
______
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______
Date of last medical exam: ______
What was the exam for? ______Current physician (medical doctor): ______
Do you see any other physicians or naturopathic healthcare providers (medical specialists, chiropractors, nutritionists, etc)? If so, please list name(s) and reason(s).
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Do you have a family history of:
Diabetes (type 1 or 2)? ______
Heart disease, high blood pressure, heart attack or stroke? ______
Cancer? ______
Alzheimer’s? ______
To the best of my knowledge, the questions above have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
Signature of patient, parent or guardian: ______Date: ______