Medical History

Although we primarily treat the area in and around your mouth, your mouth is a part of your entire body and your overall health history could possibly affect treatment.


Are you currently under a physician's care?
Yes
No

Have you ever been hospitalized or had a major operation?
Yes
No

Have you ever had a heart attack or a stroke?
Yes
No

Are you allergic to any of the following?


Aspirin
Metal
Sulfite
Penecillin
Latex
Other
Codeine
Sulfa Drugs
Acrylic
Local Anesthetics

Are you taking any medications, pills or drugs?
Yes
No

Do you use tobacco in any form?
Yes
No

Do you drink alcohol?
Yes
No

Do you use any controlled substances?
Yes
No

Do you use any illicit drugs?
Yes
No

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


AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Yellow Jaundice
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Diziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Hearbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psyciatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsilitis
Tuberculosis
Tumors or Growths
Ulcers
Veneral Disease


Premedication may be required if:

Have you ever been premedicated for a dental appointment?
Yes
No

Have you ever had endocarditis before?
Yes
No

Do you have any congenital heart conditions?
Yes
No

Do you have anything artificial in your heart?
Yes
No

Have you ever had a joint replacement?
Yes
No

Risk of Osteonecrosis:

Have you ever taken Fosamax, Boniva, Actonel, Zometa, Bonefos, or any medication containing bisphosphonate?
Yes
No

Have you ever had Bone Metastases, Multiple Myeloma, a Hypercalcemia, Osteoporosis or Paget's Disease?
Yes
No

Have you ever had chemotherapy?
Yes
No

Have you ever had radiation to the head and/or neck region?
Yes
No

Risk of Bleeding:

Are you taking any blood thinning medications (Coumadin, Plavix, Aspirin, etc.)? Most Recent INR, if applicable:
Yes
No

Do you have any conditions that will affect your ability to clot?
Yes
No

Have you ever had issues clotting?
Yes
No

Do you have a history of alcoholism?
Yes
No

Diabetic Section Only:

If you are a diabetic, are your sugar levels under control?
Yes
No




Women's Section Only:

Are you pregnant or trying to get pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking any oral contraceptives?
Yes
No


To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.