New Medical History Form Patient Name *Age *Name of Physician / and their specialtyDate of most recent physical examinationPurposeWhat is your estimate of your general health?ExcellentGoodFairPoor DO YOU HAVE or HAVE YOU EVER HAD:hospitalization of illness or injuryYesNoan allergic or bad reaction to any of the following:aspirin, ibuprofenacetaminophen, codeinpenicillinerythromycintetracyclinesulfalocal anestheticflouridemetals (nickel, gold, silver, etc)latexnutsfruitsotherheart problems, or cardiac stent within the last six monthsYesNohistory of infective endocarditisYesNoartificial heart valve, repaired heart defect (PFO)YesNopacemaker or implantable defibrillatorYesNoorthopedic implant (joint replacement)YesNorheumatic or scarlet feverYesNohigh or low blood pressureYesNoa stroke (taking blood thinners)YesNoanemia or other blood disorderYesNoprolonged bleeding due to a slight cut (INR > 3.5)YesNopneumonia, emphysema, shortness of breath, sarcoidosisYesNotuberculosis, measles, chicken poxYesNoasthmaYesNobreathing or sleep problemsYesNokidney diseaseYesNoliver diseaseYesNojaundiceYesNothyroid, parathyroid disease, or calcium deficiencyYesNohormone deficiencyYesNohigh cholesterol or taking statin drugsYesNodiabetes (HbA1c)YesNostomach or duodenal ulcerYesNodigestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)YesNoosteoporosis/osteopenia (i.e. rheumatoid arthritis, lupus, scleroderma)YesNoglaucomaYesNocontact lensesYesNohead or neck injuriesYesNoepilepsy, convulsions (seizures)YesNoneurologic disorders (ADD/ADHD, prion disease)YesNoviral infections and cold soresYesNoany lumps or swelling in the mouthYesNohives, skin rash, hay feverYesNoSTI/STD/HPVYesNohepatitisYesNotumor, abnormal growthYesNoradiation therapyYesNochemotherapy, immunosuppressive medicationYesNoemotional difficultiesYesNopsychiatric treatmentYesNoantidepressant medicationYesNoalcohol/recreational drug useYesNo ARE YOU:presently being treated for any illnessYesNoaware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)YesNotaking medication for weight managementYesNotaking dietary supplementsYesNooften exhausted or fatiguedYesNoexperiencing frequesnt headachesYesNoa smoker, smoked previously or use smokeless tobaccoYesNotaking birth control pillsYesNoconsidered a touchy/sensitive personYesNodiagnosed with a prostate disorderYesNooften unhappy or depressedYesNocurrently pregnantYesNoList all current medications *0 / 400Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, collagen injections)0 / 400PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.Submit formPlease do not fill in this field.
