History Medical

HISTORY MEDICAL

PATIENT NAME ______Birth Date______

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.

Are you under a physician's care now?YesNoIf yes, please explain: ______

Have you ever been hospitalized or had a major operation?YesNoIf yes, please explain: ______

Have you ever had a serious head or neck injury?YesNoIf yes, please explain: ______

Are you taking any medications, pills, or drugs?YesNoIf yes, please explain: ______

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

Are you on a special diet?YesNo

Do you use tobacco?YesNo

Do you use controlled substances?YesNo

Women: Are you Pregnant/Trying to get pregnant? Yes NoTaking oral contraceptives?YesNoNursing?YesNo

Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalLatexLocal Anesthetics

OtherIf yes, please explain:

Do you have, or have you had, any of the following?

AIDS/HIV PositiveYesNoCortisone MedicineYesNoHemophiliaYesNoRenal DialysisYesNo

Alzheimer's DiseaseYesNoDiabetesYesNoHepatitis AYesNoRheumatic FeverYesNo

AnaphylaxisYesNoDrug AddictionYesNoHepatitis B or CYesNoRheumatismYesNo

AnemiaYesNoEasily WindedYesNoHerpesYesNoScarlet FeverYesNo

AnginaYesNoEmphysemaYesNoHigh Blood PressureYesNoShinglesYesNo

Arthritis/GoutYesNoEpilepsy or SeizuresYesNoHives or RashYesNoSickle Cell DiseaseYesNo

Artificial Heart ValveYesNoExcessive BleedingYesNoHypoglycemiaYesNoSinus TroubleYesNo

Artificial JointYesNoExcessive ThirstYesNoIrregular HeartbeatYesNoSpina BifidaYesNo

AsthmaYesNoFainting Spells/DizzinessYesNoKidney ProblemsYesNoStomach/Intestinal DiseaseYesNo

Blood DiseaseYesNoFrequent CoughYesNoLeukemiaYesNoStrokeYesNo

Blood TransfusionYesNoFrequent DiarrheaYesNoLiver DiseaseYesNoSwelling of LimbsYesNo

Breathing ProblemYesNoFrequent HeadachesYesNoLow Blood PressureYesNoThyroid DiseaseYesNo

Bruise EasilyYesNoGenital HerpesYesNoLung DiseaseYesNoTonsillitisYesNo

CancerYesNoGlaucomaYesNoMitral Valve ProlapseYesNoTuberculosisYesNo

ChemotherapyYesNoHay FeverYesNoPain in Jaw JointsYesNoTumors or GrowthsYesNo

Chest PainsYesNoHeart Attack/FailureYesNoParathyroid DiseaseYesNoUlcersYesNo

Cold Sores/Fever BlistersYesNoHeart MurmurYesNoPsychiatric CareYesNoVenereal DiseaseYesNo

Congenital Heart DisorderYesNoHeart Pace MakerYesNoRadiation TreatmentsYesNoYellow JaundiceYesNo

ConvulsionsYesNoHeart Trouble/DiseaseYesNoRecent Weight LossYesNo

Have you ever had any serious illness not listed above?YesNoIf yes, please explain:______

______Comments: ______

______

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or 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 ______