Patient Name Nickname Age Name of Physician/and their specialty Purpose What is your estimate of your general health? ExcellentGoodFairPoor DO YOU HAVE or HAVE YOU EVER HAD: (YES/NO) hospitalization for illness or injury YesNo an allergic or bad reaction to any of the following aspirin, ibuprofen, acetaminophen, codeinepenicillinerythromycintetracyclinesulfalocal anestheticfluoridechlorhexidine (CHX)metals (nickel, gold, silver)latexnutsnutsfruitother heart problems, or cardiac stent within the last six months YesNo history of infective endocarditis YesNo artificial heart valve, repaired heart defect (PFO) YesNo pacemaker or implantable defibrillator YesNo orthopedic implant (joint replacement) YesNo rheumatic or scarlet fever YesNo high or low blood pressure YesNo a stroke (taking blood thinners) YesNo anemia or other blood disorder YesNo prolonged bleeding due to a slight cut (INR > 3.5) YesNo pneumonia, emphysema, shortness of breath, sarcoidosis YesNo chronic ear infections, tuberculosis, measles, chicken pox YesNo asthma YesNo breathing or sleep problems (i.e. sleep apnea, snoring, sinus) YesNo kidney disease YesNo liver disease YesNo jaundice YesNo thyroid, parathyroid disease, or calcium deficiency YesNo hormone deficiency YesNo high cholesterol or taking statin drugs YesNo diabetes (HbA1c = ) YesNo stomach or duodenal ulcer YesNo digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia) YesNo osteoporosis/osteopenia (i.e. taking bisphosphonates) YesNo arthritis YesNo autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma) YesNo glaucoma YesNo contact lenses YesNo head or neck injuries YesNo epilepsy, convulsions (seizures) YesNo neurologic disorders (ADD/ADHD, prion disease) YesNo viral infections and cold sores YesNo any lumps or swelling in the mouth YesNo hives, skin rash, hay fever YesNo STI/STD/HPV YesNo hepatitis YesNo If yes, what type: HIV/AIDS YesNo tumor, abnormal growth YesNo radiation therapy YesNo chemotherapy, immunosuppressive medication YesNo emotional difficulties YesNo psychiatric treatment YesNo antidepressant medication YesNo alcohol/recreational drug use YesNo ARE YOU: presently being treated for any other illness YesNo aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea) YesNo taking medication for weight management YesNo taking dietary supplements YesNo often exhausted or fatigued YesNo experiencing frequent headaches YesNo a smoker, smoked previously or use smokeless tobacco YesNo considered a touchy/sensitive person YesNo often unhappy or depressed YesNo taking birth control pills YesNo currently pregnant YesNo diagnosed with a prostate disorder YesNo Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections) List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose Drug Purpose Drug Purpose Drug Purpose Drug Purpose PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING Patient’s Signature Date Doctor’s Signature Date
