Medical HistoryPlease fill in all required fields. Name * First Name Last Name Select * Are you now under the care of a physician? Yes No If yes, please explain: Have you had any serious illnesses, or have you been hospitalized in the last 5 years? If yes, please explain. * Indicate which of the following conditions you have or have had. * By checking the box it will indicate a "YES" response, leaving it blank will indicate a "NO" response. Allergy-Chlorhexidine Allergy-Acrylic Allergy-Aspirin Allergy-Codeine Allergy-Darvocet Allergy-Jewelry Allergy-Latex Allergy-Local Anesth Allergy-Metal Allergy-Other Allergy-Penicillin Allergy-Red Dye Allergy-Sulfa Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis Artificial Heart Valve Artificial Joints Asthma Blood Disease/Disorder Blood Thinners Breathing Problems Bruise Easily Cancer Chemotherapy Cold Sores Congenital Heart Disease Cortizone Medication Diabetes Drug Addiction Emphysema Epilepsy/Seizures Excessive Bleeding Excessive Thirst Fainting/Dizziness Frequent Cough Frequent Headaches Glaucoma Gout Hay Fever Heart Disease Heart Murmur Heart Pacemaker Hemophilia Hepatitis B Hepatitis C High Blood Pressure High Cholesterol HIV/AIDS Hives/Rash HPV Hypoglycemia Intestinal Disease Irregular Heartbeat Kidney Disease Leukemia Liver Disease Malignant Hypertherm Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatment Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Sickle Cell Disease Sinus Problems Sjogren's Stroke Swelling of Limbs Thyroid Disease TMJ Tonsillitis Tuberculosis Tumors None of the Above Recent hospitalization (illness or injury) * yes no Presently being treated for any other illness/conditions? * yes no Have you had a head or neck injury? * yes no Have a cough that produces blood? * yes no Been exposed to anyone with Tuberculosis? * yes no Use tobacco - smoke, vape, or chew? * yes no Have a chemical dependancy? * yes no Have an alcohol dependancy? * yes no Use marijuana medically or recreationally? * yes no Have you had the HPV vaccination? * yes no Do you suffer from Dry Mouth? * yes no Are you on a special diet? * yes no Have you ever been diagnosed with Endocarditis? * yes no Have you ever had Rheumatic Fever? * yes no Have you ever had Mitral Valve Replacement? * yes no If any conditions or alerts selected above need further clarification, please describe below: Women Only: Please select all that apply: Currently Pregnant Currently Nursing Currently Taking Birth Control Hormone Replacement Therapy Are you presently being treated or scheduled to begin treatment using bisphosphonates such as (Fosamax, Boniva, Aredia, Zometa, etc.) for bone density therapy? * yes no If yes, start date: Have you ever been treated with bisphosphonates (Fosamax, Boniva, Aredia, Zometa, etc.) for bone density therapy? * yes no If yes, what date did the therapy medication end? Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? * yes no Do you take antibiotic premedication for your dental visits? * yes no If yes, please explain your need to premedicate: Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment. Are you taking or have you recently taken prescription or over the counter medication? * yes no If yes, please list all including vitamins, herbal, natural and/ or dietary supplements. Please list any medications you are currently taking, one medication per line. Physician name and phone number: Pharmacy name and phone number. Dental History * Previous dentist name and phone number: Date of most recent dental exam and dental x-rays: * What is the reason for your dental visit today? * Is there anything about the appearance of your smile that you would like to change? Please check all that apply: * Food gets trapped in spaces Bad mouth odor Have/had loose teeth Have broken fillings Missing teeth Teeth sensitive to cold, hot, sweets or pressure Experience Dry Mouth Periodontal (gum) treatment Orthodontic treatment (braces) Had any problems associated with previous dental treatment Drink bottled or filtered water Currently experiencing dental pain or discomfort Have/had earaches or neck pain Have any clicking, popping or discomfort in the jaw Brux or grind your teeth Have/had sores or ulcers in your mouth Wear dentures or partials Have/had a serious injury to your head or mouth None of the above Sleep Apnea * Please check all that apply: Snore loudly Feel fatigued or sleepy during the daytime You stop breathing, choke or gasp during your sleep Currently using CPAP None of the above If any of the checked boxes need further explanation, please describe: By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. * This will serve as my electronic signature. Thank you!
